
TUBERCULOSIS 

ITS CAUSE CURE AND PREVENTION 



EDWARD O. OT1S.M.D. 




Class /T'C '%//. 

Book yJL 






Copyright^ ^ 



COPYRIGHT DEPOSIT 




(fl-^p/l. 



Discoverer of the Tubercle Bacillus. 



TUBERCULOSIS: 

ITS CAUSE, CURE 
AND PREVENTION 



A REVISED EDITION OF 

"THE GREAT WHITE PLAGUE" 
(A BOOK FOR LAYMEN) 

BY 
EDWARD O. OTIS, M.D. 

Professor of Pulmonary Diseases and Climatology, Tufts College 
Medical School ; late President of the Boston Tuberculosis 
Association; late Visiting and Consulting Physician to 
the Massachusetts State Sanatorium ; member of the 
National Tuberculosis Association; Correspond- 
ing Member of the International Anti- 
Tuberculosis Association, etc. ( etc. 



NEW YORK 

THOMAS Y. CROWELL COMPANY 

PUBLISHERS 



FfC ail 
.(Dtf 



Copyright, 1909, 
By THOMAS Y. CROWELL & CO. 

Copyright, 1914, 
By THOMAS Y. CROWELL COMPANY, 



Published March, 191 



MAR 18 1914 

©CI.A362930 



LC Control Number 




tmp96 028682 



TO GEORGE ADAMS LELAND, M. D. 

A friend of years, through whose kindly in- 
terest this book was written. 



" The Modem Crusade against tuberculosis 
brings hope and bright prospects of recovery 
to hundreds and thousands of victims of the 
disease who under old teachings were aban- 
doned to despair/' 

Theodore Roosevelt. 



PREFACE 

In the following pages an attempt has been 
made to present the simple facts of tuberculo- 
sis in such a form as will be intelligible and 
interesting to the layman. A decade or more 
ago, no one would have entertained the idea 
of publishing a popular book upon this sub- 
ject; but since that time the great Crusade 
against tuberculosis has become so universal 
and prominent, that to-day the subject excites 
the deepest interest in almost every commu- 
nity, and the people are everywhere eager to 
learn the essential facts with regard to its 
cause and cure. 

Many things have been repeated advisedly, 
as the subject has been viewed from differ- 
ent standpoints. Naturally there still remain 
unsettled problems upon tuberculosis; but 
the narrative has been presented in the light 
of the present knowledge of the subject, and 
with an absolute adherence to definitely es- 
tablished facts. Thanks to the unceasing ef- 
forts of investigators in many lands, we now 
possess sufficient knowledge of so final and 
V 



PREFACE 

definite a character as to render it possible to 
wage this momentous campaign with an as- 
sured hope of success in the prevention and 
ultimate eradication of the " Great White 
Plague." Wonderful strides have been made, 
in the last few years, in both discovering the 
secrets of this world-wide disease, and also in 
educating the general public upon the subject. 
The future prospect is most hopeful; and the 
rapidity with which the end can be achieved 
will depend upon the efforts of every indi- 
vidual, and the material aid which both people 
and governments will contribute towards it. 

E. O. O. 
Boston, July I, 1909. 



PREFACE TO REVISED EDITION 

Since this book was published under the 
title of " The Great White Plague," four and a 
half years ago, no startling discovery has been 
made either regarding the nature or the cure 
of tuberculosis; nor have the methods of 
fighting the disease been materially changed. 
The open-air treatment still maintains its su- 
premacy, and experience has demonstrated the 
value of the preventive measures then in use. 
Only, the fight has become more universal, 
more determined, and more intense, with 
larger forces and material resources. In this 
revision the form and substance of the book 
have been retained and only such changes and 
additions have been made as new data and in- 
creased experience and knowledge have ren- 
dered necessary to bring it up to date. 

Tuberculosis still prevails to an enormous 
extent, but it is steadily decreasing, with no 
reason to suppose that it will not continue to 
do so, though with perhaps lessened rapidity. 
The past success brings courage and hope, and 
" so long as we are fighting with hope," says 
Sir William Osier, " the victory is in sight." 

E. O. O. 

Boston, January i, 1914. 

vii 



CONTENTS 

CHAP. p AGE> 

I. Tuberculosis, Its Prevalence and 

Its Significance ...-.,. I 

Great epidemics of the Middle Ages — 
Universality of Tuberculosis! — Tuber- 
culosis compared with great disasters 
and wars — The old feeling of hopeless- 
ness — The saddest fact of all — Tuber- 
culosis and pneumonia compared — 
Economic loss from tuberculosis — Ef- 
fect upon different races — Sex and 
tuberculosis. 

II. What Is Tuberculosis? Its Na- 

ture and Cause . ... 23 
Description and location — Dr. Koch's 
discovery — Value of animal experimen- 
tation — Nature of the tubercle bacillus 
— Dry sputum alone dangerous — How 
to control the disease — A "house dis- 
ease" — How bacilli enter the body — 
Infected milk. 

ix 



CONTENTS 

CHAP. PAGE. 

III. Tuberculosis a Contagious or In- 

fectious Disease: What This 
Means 38 

What is a contagious or infectious dis- 
ease ? — Acute infectious diseases — 
Chronic contagious diseases — " Con- 
sumption terror " — The only way con- 
sumption is conveyed. 

IV. Inheritance and Immunity . 47 

The old idea versus the new — What 
is "inheritance?" — Predisposition and 
immunity — Antitoxins and vaccines — 
Immunity in acute diseases. 

V. The Seed and Soil 58 

Two things necessary to contagion — 
The favorable soil — The " neglected 
cold " — Overcrowding as a cause of 
tuberculosis — Fresh air and sunshine — 
Evils of inadequate respiration — Value 
of proper food — Defective teeth — Al- 
cohol makes the bed of tuberculosis — 
Injurious occupations — Over-fatigue 
and over-exertion — Worry — Monotony 
of occupation. 

VI. The Recognition and Symptoms 

of Tuberculosis 82 

Early symptoms — How the lungs are 



CONTENTS 

CHAP. PAGE. 

tested — Examination of the sputum — 
The tuberculin test — The X-Ray — 
" Closed " tuberculosis — The only safe 
way — Points to remember. 



VII. The Curability of Tuberculosis 

and Its Treatment .... 98 
Formerly regarded as hopeless — Useless 
remedies — The true theory of treat- 
ment — The out-door treatment — From 
in-door to out-door life — Rest in the 
cure — The sanatorium and its advan- 
tages — Alleged objections to the sana- 
torium — No medicine used in the 
sanatorium — Seventy per cent, cured or 
arrested in the early stage. 



VIII. The Home Treatment of Tu- 
berculosis 118 

The room of the consumptive — Care of 
the sputum — How the day should be 
spent — Day camps and classes — Sleep- 
ing arrangements — Exercise — Food — 
The hardening process and the cold 
bath — Clothing — Precautions and mode 
of life after recovery — A suggestive 
daily routine — Some aphorisms of the 
tuberculosis patient. 
xi 



CONTENTS 

CHAP. PAGE. 

IX. Tuberculosis and Climate . . 142 

Unhygienic conditions in cities — Con- 
sumption rare in out-door life — Climate 
only one factor — The most favorable 
climate — Why a change of climate — 
Selection of a climate — The essential 
climatic factors — Various health resorts 
in America — Health resorts in Europe 
— Dr. Knopf's ideal climate. 

X. The Prevention of Tuberculosis 163 

The direct attack — The educational cam- 
paign — The tuberculosis exhibition — 
The traveling exhibition — The service 
of the public press — Cumpulsory noti- 
fication — The tuberculosis dispensary 
— The isolation of the dangerous con- 
sumptive — Compulsory notification and 
disinfection no new thing 1 — Methods of 
disinfection — The indirect means of 
prevention — Tuberculosis a social dis- 
ease — Better tenement houses — Prohi- 
bition of liquor — Pure air — Important 
points to remembei — A clean house 
and dust — Spitting and cuspidors. 

XL The Great Crusade against Tu- 
berculosis 193 

Organized efforts almost universal — In- 
ternational congresses — The move- 
xii 



CONTENTS 

CHAP. PAGE. 

ment simultaneous among all peoples 
— Why a crusade against a single dis- 
ease — Principal forms of activity — 
Germany — Compulsory insurance of 
workingmen — Information bureaus — 
Other forms of tuberculosis work in 
Germany — England — Ireland — France 
— Sweden — Denmark — Switzerland — 
Belgium — Norway — Tuberculosis work 
in other countries — Canada and Breh- 
mer Rest — The tuberculosis crusade in 
the United States — The price of a bat- 
tleship for the tuberculosis crusade — 
What the United States Government is 
doing — The National Tuberculosis As- 
sociation — The Red Cross stamps — 
The clergy and churches and societies 
— Governors and legislatures — New 
York — Pennsylvania — Massachusetts — 
Scientific activity in the study of tuber- 
culosis — Effect of the tuberculosis cru- 
sade. 



XII. Tuberculosis and the Child . 227 

How children contract tuberculosis — 
Milk infection — House infection— ^Tu- 
berculosis not decreasing in children — 
Children in infected homes — A tuber- 
culous mother should not nurse her 
infant — Feeding school children — How 
to treat children with tuberculosis — A 
xiii 



CONTENTS 

CHAP. PAGE. 

typical out-door school — Hygienic 
school buildings — Rules for children — 
Teachers and tuberculosis — The home 
and tuberculosis — A complete pro- 
gramme. 

XIII. The Government and Tuber- 
culosis 252 

The government should protect the 
health of the people — What former 
President Roosevelt says — State gov- 
ernments and tuberculosis — A compre- 
hensive scheme for the state — City 
governments — Large appropriations 
necessary — What foreign nations are 
doing. 

XIV. The Factory and the Work- 
shop in Their Relation to Tu- 
berculosis 266 

Importance of protecting the health of 
wage-earners — Remedies for evils of 
industrial infection — What is now be- 
ing done — The plan of mutual aid in 
Connecticut — Better conditions of fac- 
tory life — Mortality from dusty trades 
— The peril of the sweat shops — The 
remedy for dust in factories — Depart- 
ment stores and shops — Waiters, nurse 
girls, and servants — Tuberculosis in 
prisons — Tuberculosis in insane asy- 
lums. 

xiv 



CONTENTS 

CHAP. PAGE. 

XV. The Future Outlook . . . 288 

Resolutions of the International Con- 
gress — A look forward — some statis- 
tics of the diminution of tuberculosis 
— The advance in the future — The open- 
air school in the future — Another influ- 
ence, peace between nations. 

XVI. The Lungs and Their Use . 305 

Why do we breathe? — The cavity which 
contains the lungs — The mechanism of 
respiration — The upper respiratory 
tract — Size, weight and capacity of the 
lungs — Inadequate respiration a danger 
— We should breathe through the nose 
— Importance of pure, fresh air — Res- 
piratory exercises — The corset — The 
habit of full, free respiration. 

Fresh Air . ; . . 322 

Health Rules 323 



xv 



ILLUSTRATIONS 

Robert Koch, Discoverer of the Tubercle 

Bacillus . . . . . . Frontispiece 

OPPOSITE PAGE 

Theophile Laennec, Discoverer of Aus- 
cultation 86 

Sleeping with Heads out of the Windows ioo 

Sleeping Porches 106 

A Winter's Day at the Sanatorium — A 

Sun Bath no 

The " Shack " for the Open-Air Treat- 
ment 116 

The Walsh Window Tent 120 

Keeping Warm in Winter while Taking 

the Cure 124 

Sleeping Out-of-Doors, " the Sky for a 
Roof" 132 

Davos in Switzerland, the Great Resort 

for the Tuberculous 160 

A Tuberculosis Dispensary .... 172 

The Vanderbilt East River Homes . . 208 

An Open-Air School Room in Boston . 242 

An Open-Air School in Philadelphia . 246 

Rest Hour in an Open-Air School . . 250 

A Typical Open-Air School .... 300 



I. TUBERCULOSIS— ITS PREVALENCE 
AND ITS SIGNIFICANCE 

CUBERCULOSIS or consumption 
has been aptly called the " Great 
White Plague." We might also 
call it the " Silent White Plague," 
for although it is a veritable 
plague in its universal and great prevalence, 
as we shall see directly, yet it so slowly and 
silently seizes upon its victims, and the world 
has grown so accustomed to it, that it pos- 
sesses little of that dramatic incident attend- 
ant upon its ravages that the plague of old 
had in its sudden and appalling visitation 
upon a community, when, as Daniel Defoe 
said in his famous description of the plague 
in London in 1665, " Men everywhere began 
to despair; every heart failed them for fear; 
people were made desperate through the an- 
guish of their souls, and the terror of death 
sat in the countenances of the people." 



TUBERCULOSIS 

The plague of old, however, with its almost 
incredible mortality, decimating the inhabit- 
ants of a country in a short time, accom- 
plished its fatal work and was done. The 
present white plague, tuberculosis, is never 
done with its insidious work; for numberless 
years it has been silently, continuously and 
unrelentingly pursuing its destructive course, 
never remitting its deadly work, always reach- 
ing out for new victims, and to-day it is the 
most universal scourge of the human race. It 
is hardly conceivable that in any modern 
country or city of the world any such ravages 
of the plague of old should again occur, such, 
for example, as happened in Marseilles in 
1720, when 80,000 people were destroyed by 
it in a short time, and in London in 1665, when 
70,000 inhabitants perished, while Italy was 
said to have lost half its inhabitants from it, 
and over one million died in Germany. 

Neither do we attribute to inscrutable 
providence or to nature the " desolation of 
great pestilences " as did, in their ignorance, 
the pious men of old. Science has revealed 
to us that it was not omnipotence or nature 
which afflicted mankind with pestilential dis- 

2 



ITS PREVALENCE 

eases, but man himself through his own igno- 
rance and uncleanliness. On the contrary 
rather, we can with greater justice affirm that 
it was the hand of a beneficent providence 
which revealed to man the causes of these 
epidemic diseases and their prevention, and 
which brought to mankind through the great 
scientist, Louis Pasteur, those wonderful 
words of hope so often quoted : " It is in the 
power of man to cause all parasitic (germ) 
diseases to disappear from the world." 

We now know that the plague was an in- 
fectious or germ disease like all the other 
great epidemic diseases ; and it was caused by 
a germ known as the " bacillus pestis." We 
also know that the " favorable soil," as we 
call it, for its ravages, was the uncleanliness 
of the mediaeval cities, which abounded in filth 
and possessed no sanitation in the modern 
sense of the word. When once cleanliness and 
improved sanitation, such as now exist in all 
modern cities, came into existence, the con- 
ditions for the spread of the plague were lack- 
ing, and it has now practically disappeared 
from modern civilized centers. 



TUBERCULOSIS 

Great Epidemics of the Middle Ages 

Such is also the case with other of the great 
epidemics of the middle ages, — one after an- 
other they have been for the most part elim- 
inated by modern methods of prevention and 
sanitation, such as Asiatic cholera, yellow 
fever, typhus fever, epidemic dysentery and 
others. Small-pox was a genuine scourge to 
mankind until the immortal Jenner discovered 
vaccination in 1796, and now it only occurs 
in cases where vaccination has been neglected. 
Leprosy, which is also an infectious disease 
caused by a germ or bacillus very similar to 
the bacillus of tuberculosis, existed all over 
Europe in the middle ages. In the reign of 
Louis VIII. of France there were 2,000 leper 
houses or asylums in that country alone, while 
in Great Britain such houses were dotted all 
over the land. At the present time, as we 
know, a case of this disease is a rare occur- 
rence among us. Better knowledge of the 
causes of these diseases, cleanliness, better 
sanitation and individual hygiene have con- 
quered them, and in consequence the horrors 
of great epidemics have vanished, and one's 
expectancy of life is increased from an aver- 
4 



ITS PREVALENCE 

age of less than fifteen years in 1643 to more 
than forty years at the present time, and the 
average annual death rate throughout the 
civilized world has been reduced from fifty or 
more per each 1,000 of the population in the 
seventeenth and eighteenth centuries to less 
than half that number at the present time. 

If we could only eliminate all infectious or 
contagious diseases, what an immeasurable 
boon would be conferred upon mankind, and 
upon generations yet unborn ! What has been 
accomplished with the single contagious dis- 
ease, diphtheria, by antitoxin, which has re- 
duced its mortality from about 40 per cent, to 
12 per cent., and even much less if used early 
enough, we may confidently hope will be 
accomplished in time with other similar 
contagious diseases. Towards this goal a 
thousand investigators are working in the 
laboratories of research and in the hospital 
clinics. 

Universality of Tuberculosis 

Tuberculosis still remains, however, as the 
most destructive and universal disease which 
afflicts mankind. " In all climates/' says Dr. 
Ransome, " in the North, and in the South, 

5 



TUBERCULOSIS 

East and West, however various the conditions 
under which men live, however much they may 
differ in race, in diet, and clothing, and in 
habits of life, wherever human beings are con- 
gregated together there tuberculosis is to be 
found." Although tuberculosis exists among 
all classes of society, in the homes of the rich 
and in the tenements of the poor, yet it is far 
more prevalent among the " poor and starv- 
ing," for misery and poverty are powerful pre- 
disposing causes. It has, therefore, been well 
called a " social evil," a " disease of the 
masses," for so often is the tuberculosis in- 
dividual a victim of social conditions which it 
is impossible for him to overcome ; the work- 
man cannot change the bad air of his work- 
shop, or live in a model tenement, or always 
obtain sufficient and nutritious food. In 
Budapest, for example, Dr. Korosi found that 
consumption caused 22 per cent, of all deaths 
among the poor, but only 16 per cent, among 
the well-to-do. The Germans call tuberculo- 
sis the disease of the common people, " Volks- 
krankheit." 

" Every other resident adult you meet in 
the streets," wrote Dr. Oliver Wendell Holmes 
6 



ITS PREVALENCE 

in 1867, " is or will be more or less tuber- 
culous." And a German authority has re- 
cently declared that one-half of all deaths and 
one-half of the sickness among adults in Ger- 
many can be charged to tuberculosis. In that 
country — Germany — the present yearly mor- 
tality from this disease is about 100,000. In 
France the yearly mortality is 88,000, and in 
the city of Paris it is about 9,600, which is 
nearly one-fifth of the whole number of 
deaths, and three times as many deaths as 
from all the other contagious diseases together. 
In Great Britain and Ireland the annual sacri- 
fice is 75,000, and in the city of London about 
9,600. In 1904 in England tuberculous dis- 
eases caused sixty deaths to sixty-seven 
caused by the combined chief acute infectious 
diseases, namely: — measles, whooping cough, 
diarrhoea and dysentery, typhoid fever, diph- 
theria, scarlet fever, small pox and typhus 
fever. In Austria the yearly mortality is over 
80,000; and in the city of Vienna over 5,000; 
in Italy 50,000 to 60,000; and in the United 
States 150,000 or more, or one death about 
every three minutes. In the State of Pennsyl- 
vania it is 8,000 and in New York State over 
14,000 or ten per cent, of all deaths. In 

7 



TUBERCULOSIS 

Greater New York City it is 8,500 and in Chi- 
cago 3,600. Massachusetts has a sacrifice of 
4,400 and its metropolis, Boston, 1,050. In 
New Orleans it is about 900 annually. As 
great as this mortality is it is far less than it 
was fifteen or twenty years ago as we shall 
later see. One has only to recall the conster- 
nation and terror caused by the yellow fever 
epidemic in this city (New Orleans), a few 
years ago, to remember that the mortality from 
this disease at that time was hardly 450 deaths. 
And such an epidemic is not likely to happen 
for many years, if ever again, while twice that 
number is sacrificed not only one year but year 
after year in that city. 

Tuberculosis Compared WitH Great Disasters 
and Wars 

In the volcanic eruption at Martinique 30,- 
000 souls were destroyed in an instant and the 
world was appalled at the disaster; but this 
number was only one-fifth of the yearly de- 
struction of life from tuberculosis in the 
United States. We think of the terrible catas- 
trophe from the earthquake in Sicily, and yet 
hardly more lives were destroyed than are sac- 
rificed every year from tuberculosis in the 
United States, and there may not be another 
8 



ITS PREVALENCE 

such destructive earthquake for a century, 
while tuberculosis with relentless certainty 
claims its great sacrifice every year. We 
speak of the destruction of human life from 
war, but twice as many died from tuberculosis 
in the eighteenth century as were killed in 
battle during the wars of that period. In the 
four years of our Civil War there were killed 
and mortally wounded from 155,000 to 161,- 
000, which is not much above the annual mor- 
tality from tuberculosis in this country. 

And so one might go on indefinitely reciting 
these ghastly statistics for country after coun- 
try and city after city, until the sum total of 
annual deaths from tuberculosis throughout 
the civilized world would be found to be 
1,000,000 or more, or 3,000 each day; and un- 
less conditions change, eight to ten millions of 
people now living in this country are doomed 
to death by this plague. Still, however, the 
whole story is not told, for it has been esti- 
mated by Dr. Philip of Edinburgh, after a 
careful study of the subject, that the ascer- 
tained mortality in any city can safely be 
multiplied by ten in order to represent approxi- 
mately the number of persons living already 
seriously affected, and even twice that figure, 
he thinks, would be still below the mark. In 
9 



TUBERCULOSIS 

this country (the United States), it has been 
estimated by good authority that 1,500,000 
persons are suffering annually from tubercu- 
losis. 

One is led to inquire from all this enor- 
mous extent of tuberculosis, why it is that 
anybody escapes the disease? Indeed, the 
Germans have declared that everybody does 
become affected sometime or other in his life, 
though of course it does not follow that every- 
one who becomes infected with the tubercu- 
lous germs develops the active disease or even 
is ever aware that he has had the infection. 
Autopsies, however, performed upon persons 
who have died of other diseases often show 
evidence of tuberculosis which was all un- 
known to the individual in his life-time, and 
never produced any recognizable symptoms. 

The Old Feeling of Hopelessness 

For countless years tuberculosis has 
been reaping this rich harvest, and so con- 
tinuously and silently, and yet so regularly 
has the sickle fallen that the magnitude of 
the crop was not and still is not realized; 
moreover, its victims, being ignorant of 
the cause of the disease and consequently of 
IO 



ITS PREVALENCE 

its prevention, could only exclaim, " It is the 
hand of God, and we are powerless to avert 
it." " It is the flaming sword of the destroy- 
ing angel ! " But the beginning of the end 
was at hand, and after all these years it re- 
mained for Koch with his incomparable genius 
to reveal the true cause of the disease and to 
open the way to prevention. 

The Saddest Fact of All 

In the above portrayal of the prevalence 
and mortality of tuberculosis the whole ex- 
tent of the calamity has not yet been given, 
and perhaps the saddest of all the facts con- 
nected with tuberculosis is yet to be men- 
tioned. The reader may already have in mind 
the question which is now to be answered: 
" At what age do the majority of those whose 
death is caused by tuberculosis die ? " Is it 
in infancy, youth, manhood or old age? For 
it makes a vast difference in the general and 
economic welfare of the community at what 
age so many deaths occur as those from tu- 
berculosis. If in infancy or childhood, they 
are only potential factors in the community 
of workers; or if in old age, their contribu- 
tion to the community has been made. Alas! 
ii 



TUBERCULOSIS 

tuberculosis claims its victims in the best years 
of their life, for it is the sad fact that from 
one-fourth to one-third of all deaths between 
the ages of fifteen and thirty-five or forty 
years result from this disease. In Germany 
almost one-half the deaths occurring between 
fifteen and forty years of age are from tuber- 
culosis, reaching this proportion most nearly 
between twenty-six and thirty years. In Eng- 
land and Wales, between the ages of fifteen 
and thirty-five a little less than one-third of all 
deaths are due to tuberculosis. In this coun- 
try in the registration area, that is, in those 
states where vital statistics are accessible, of 
all deaths occurring in 1907 nearly a third 
(33.2 per cent.) between the years of fifteen 
and twenty-nine were due to tuberculosis in 
some of its forms, while the deaths from pneu- 
monia, a very prevalent disease, were only 
6.7 per cent, during this age period. For ma- 
ture manhood and womanhood (30 to 44 
years) over one-fourth (25.6 per cent.) of all 
deaths were due to tuberculosis, while the 
deaths from pneumonia were only 8.8 per 
cent. For the age period of forty-five to 
fifty-nine years, the mortality is 12. 1 per cent., 
for at this period other diseases, such as heart 
12 



ITS PREVALENCE 

and kidney disease, cancer and other so-called 
degenerative diseases become more frequent. 

It is seen, then, that the majority of deaths 
from tuberculosis occur at the most valuable 
period of a person's life, the working, the re- 
productive period, the age when the life of the 
individual is of the greatest economic value to 
the community, and his death of the greatest 
economic loss. This fact is, perhaps, the sad- 
dest of all the grim facts connected with the 
ravages of tuberculosis. " The world is for- 
ever poorer," said Dr. Wilbur,* " on ac- 
count of the untimely death of Robert Louis 
Stevenson, though richer for the record of his 
brave fight against the unrelenting foe, tu- 
berculosis, that harried him to the islands of 
the great ' South Sea ' he loved, and slew him 
there. What would have been the value to 
literature of a few more years of this single 
life! and how many are now dying from tu- 
berculosis who, were they but permitted a few 
more years of healthful life, would by their 
works of genius add immensely to the treas- 
ures of humanity. Tuberculosis kills men and 
women chiefly in the most active, most pro- 
ductive period of life, when their work is 

♦Tuberculosis in the U. S. Bureau of the Census. 
13 



TUBERCULOSIS 

worth the most to themselves, to their fam- 
ilies, and to the world." 

Tuberculosis and Pneumonia Compared 

In comparing pneumonia, which has been 
referred to above, and whose mortality is 
quite equal to and sometimes a little above 
that of tuberculosis, with the latter disease, we 
find this startling difference: that whereas 
pneumonia destroys the majority of its vic- 
tims at the two extremes of life, — the young 
child before it becomes economically and so- 
cially valuable and before it has received a 
more or less expensive training for its life 
work, and the old person who has completed 
his work and made his contribution to so- 
ciety, — tuberculosis, on the other hand, gathers 
its harvest between these extremes : it " loves 
a shining mark." It clutches in its relentless 
grasp the young man just established in his 
profession or trade, the young mother in her 
family, the father upon whose working ability 
the wife and family depend, the young col- 
lege graduate with anticipations of high 
achievement, or it cuts off the genius who has 
already become famous, in the midst of his 
career. So it happened to the German poet 
14 



ITS PREVALENCE 

Schiller, and to Keats, the sweet English 
singer; to the nature-loving Thoreau, and to 
the musicians Chopin and Weber. It is in 
adult life that we accomplish our main life's 
work. As Dr. Osier tells us, our principal 
creative work and achievements are completed 
at forty years of age. It is just at this in- 
finitely valuable period that tuberculosis does 
its fatal work, and that is what makes the 
disease so dreaded and so destructive. 

Economic Loss From Tuberculosis 

Consider for a moment, in terms of dollars 
and cents, the prodigious economic loss en- 
tailed upon the community by tuberculosis. 
In the United States it has been esti- 
mated that the money loss from tuber- 
culosis is $1,235,000,000 a year; in France, 
$200,000,000 a year ; in Canada Dr. Richer es- 
timates the loss at $72,000,000, and in New 
York City Dr. Biggs has estimated that the 
annual loss to the city from tuberculosis is 
$23,000,000. The total annual loss to the State 
of Illinois after a very fair and conservative 
estimate based upon statistics has been placed 
at $36,551,000. England, in fifteen years, has 
expended $600,000,000 in combating tubercu- 
15 



TUBERCULOSIS 

losis and has saved 876,581 lives thereby, or 
in round numbers $685 apiece. Dr. News- 
holme, a health officer of England, estimates 
that in Wales alone by the abolition of tuber- 
culosis in that country not far from $50,000,- 
000 annually could be saved. " And this," he 
says, " makes no allowance for the loss sus- 
tained by protracted sickness, nor for the fur- 
ther loss from premature death of women 
from the same cause." 

Mr. Hoffman, the statistician of the Pru- 
dential Insurance Company, says that the an- 
nual cost of deaths from tuberculosis to that 
company, on a basis of three years' experience, 
is $800,000. Cornet, the German authority, 
estimates that the deaths from consumption 
in Prussia, if we reckon only one year of in- 
validism when the sufferer cannot work, cost 
that country $23,000,000 annually, and this 
does not take into account the added years of 
life and remunerative employment which 
would follow if consumption were banished. 
One can, to a degree, understand how such 
enormous losses occur if he considers the 
amount expended upon education and prepa- 
ration for work; the value of the workman 
when he has been prepared for his life's work, 
16 



ITS PREVALENCE 

which, at a very conservative calculation, has 
been estimated to be $1,500, and the value of 
his work, his support, care and nursing during 
the period before his death when he is un- 
able to work; and then there must be added 
to this, in so many cases, the support of the 
family left behind, who have been deprived of 
their bread-winner. 

Dr. Newsholme thus admirably states the 
economic value of lives lost during their best 
working period : " Each child," he says, " un- 
til he is able to support himself, is having ex- 
pended upon him, time, money and effort 
which may be regarded as so much capital 
invested with a prospect of future returns. 
If he dies in infancy, the measurable loss is 
much less than if the death is postponed until 
the age of fifteen. Between the ages of fif- 
teen and twenty, it is probably exceptional 
.for the earnings to more than balance per- 
sonal expenditure, and, if this is so, all deaths 
up to the age of twenty may be regarded as 
involving a serious loss of capital expendi- 
ture. During the next five years, a large pro- 
portion of the population marry and thus in- 
cur new obligations before the balance against 
them can possibly have been paid off. It is 
17 



TUBERCULOSIS 

during the following thirty or forty years that 
he can hope to pay back the value of his own 
earlier maintenance by personal savings and 
by investing capital in the formation of a 
home and the upbringing of a family in his 
turn. Each family represents in this respect 
an investment on the installment system, and 
the only hope of completing the investment 
and leaving no debt for the survivors to re- 
deem or owe to the community, is for the 
worker to live and remain able to work until 
all his children are able to earn their liveli- 
hood, and until his wife and himself can main- 
tain themselves in their old age. This can 
only be realized when the worker is not cut 
down by illness or killed by disease or acci- 
dent. Hence the immense economic signifi- 
cance of the fact that among men nine out of 
every ten deaths from tuberculosis occur be- 
tween the ages of fifteen to sixty-five." 

In the above consideration we have been 
attempting to estimate the loss from tubercu- 
losis in terms of economic value, in money, 
but who can estimate the suffering, the pov- 
erty, the sorrow, the blighted hopes, the loss 
of personal influence, the severed friendships 
entailed by this ever-present, cruel disease, — 
18 



ITS PREVALENCE 

a disease whose cause is now known and 
which is preventable. Thirty years ago, the 
world first learned this incomparably pre- 
cious fact, and this dark picture of the awful 
ravages of tuberculosis was illumined by the 
light of knowledge and hope. Again may 
Louis Pasteur's great saying be repeated: 
" It is in the power of man to cause all para- 
sitic (germ) diseases to disappear from the 
world." It is in the power of man to banish 
tuberculosis. 

Effect Upon Different Races 

Tuberculosis does not afflict all races or the 
sexes equally. Certain races seem to be more 
susceptible to the disease than others. In 
some cases it may be a true racial suscepti- 
bility, while in others it may be the conditions 
under which the race lives and their personal 
habits. 

Thus, the colored race in the United States 
has at the present time at least four times the 
mortality as the white race, whereas before 
the Civil War the disease was rare among the 
colored population. As slaves they lived a 
healthy outdoor life, in the country, and were 
well fed, clothed and lodged, for they were 
19 



TUBERCULOSIS 

valuable property and it was for the com- 
mercial interest of their owners to take good 
care of them. Since emancipation they have 
had no one to overlook, with such interest, 
their physical well-being; they have nocked 
to the cities, have had more confined work 
in factories and workshops, with long hours 
of work, poor pay, and often insufficient 
food; they were ignorant of the principles of 
sanitation, and have had access to cheap 
liquor. Environment, ignorance and the 
abuse of alcohol would seem to be the impor- 
tant factors in producing this high mortality 
from tuberculosis in this race. 

Again, tuberculosis is more prevalent in the 
Irish than in any other European race. This 
is especially true with this race in the United 
States. Dr. Flick} thinks this is due to a 
racial susceptibility. Probably also the 
greater confinement indoors in this country, 
and the addiction to alcoholic liquors of this 
race play an important part. 

The Indian when brought in contact with 
civilization shows a large mortality from tu- 
berculosis. This is ascribed, and probably with 
truth, to the " disastrous effect of civilization 
upon a savage race." How true it is that it 

20 



ITS PREVALENCE 

requires both education and experience to 
avail one's self of the benefits of civilization 
and avoid its evils. 

In this country the Bohemian, the Scandi- 
navian, the French, the German, the Scot, 
and the Canadian come next respectively in 
order of mortality, while the Italian and the 
Jew are lowest in the scale. Throughout the 
world the Jews have a comparatively low 
death rate from tuberculosis. This has been 
attributed to a genuine racial resisting power 
to this disease and also to their well-known 
temperance, particularly in the use of alco- 
holic drinks. 

Sex and Tuberculosis 

With regard to the influence of sex upon 
the mortality from tuberculosis, at the pres- 
ent time the male mortality is somewhat in 
excess of that of the female. In earlier years, 
however, both in England and in the State of 
Massachusetts, where alone statistics upon 
this point were at hand, the reverse was the 
fact. One of the reasons for this change may 
be the increased outdoor life which has be- 
come popular among women of late years, and 
another, the general movement now going on 
21 



TUBERCULOSIS 

throughout the civilized world for the physi- 
cal and social amelioration of the condition of 
working-women. Furthermore, the enormous 
increase in manufacturing, and the consequent 
congestion of population has added to the 
risks to life and health of the male laborer. 
The early simple life was as conducive to 
physical well-being as to moral and spiritual 
health. 



22 



II. WHAT IS TUBERCULOSIS? ITS 
NATURE AND CAUSE 

CUBERCULOSIS is a disease 
which may affect any part of the 
body and is characterized by the 
formation of " tubercles " which 
are at first tiny bodies or nodules 
detected by the microscope and which increase 
in size as the disease advances. These tu- 
bercles destroy the tissues in whatever part of 
the body they occur, and, if in the lungs, 
where they are most commonly found, their 
tendency is to ever extend their field of de- 
struction like the march of an invading army. 

Description and Location 

Different names are often given to tubercu- 
losis as it affects different parts of the body; 
thus, tuberculosis of the hip is called " hip 
joint disease " ; tuberculosis of the knee or 
ankle, " white swelling " ; of the skin, " lu- 
pus " ; and of the glands of the neck, " scrof- 
ula." In other cases we simply speak of tu- 

23 



TUBERCULOSIS 

berculosis as of this or that part of the body, 
as tuberculosis of the bones, the kidneys, 
throat, bowels, etc. Tuberculosis of the 
lungs, called " consumption " or " phthisis," 
is the most common form of the disease, 
nearly nine-tenths of all tuberculosis being 
that of the lungs. 

It is in fact a very old disease, and like 
other infectious diseases, nobody knows how 
or when it had its origin. Somehow it was 
evolved in the process of civilization like 
many other evils, and is one of the penalties 
we have to pay for the many good things 
civilization has brought us. " It is a disease 
of all times, of all countries, and of all races." 
Hippocrates, a renowned Greek physician who 
lived about 400 b. c, gave a very excellent 
description of the disease, and from that time 
to the present medical writers have recog- 
nized and described it. 

The cause of tuberculosis was ascribed to 
various influences: thus, Hippocrates thought 
it was due to some poison in the air wafted by 
the winds from one place to another. Other 
old writers upon the subject ascribed it to the 
use of chimneys in houses, to smoke from 
wicks of candles, excess of animal food, and 
24 



ITS NATURE AND CAUSE 

to tight lacing and stays. A keen and wise 
observer was he who ascribed it to this lat- 
ter cause. It seems almost startling that the 
world should have remained all these hun- 
dreds of years in ignorance of its cause until 
a man recently living, finally in the fullness 
of time, discovered the true cause and proved 
it so perfectly and completely that no one has 
ever been able to disprove it. 

Dr. Koch's Discovery 

It was in 1882 that Dr. Robert Koch made 
this marvelous discovery; the hour and the 
man had arrived and the great light shone. 
The blessings which this discovery has con- 
ferred upon humanity, and will continue to 
bestow as time goes on, are almost incalcula- 
ble, for all our direct measures for the pre- 
vention and control of tuberculosis depend 
upon the knowledge of its cause. 

The manner and method of Dr. Koch in 
making this discovery are of intense interest. 
Villemin, a French investigator, had success- 
fully demonstrated in 1865, by experiments 
upon animals, that tuberculosis was infec- 
tious, or, to use a better term, " communica- 
25 



TUBERCULOSIS 

ble," but he did not discover the cause of the 
infection. Many others at earlier dates had 
also believed in the infectious nature of the 
disease and stringent laws were enacted re- 
garding its isolation, and disinfection: thus, 
in 1638 Lazarus Riverius, who wrote a book 
on medicine called " Practice of Physik," 
says : " Moreover, there are causes of tuber- 
culosis of the lungs, as contagion, which is 
the chiefest, for this disease is so infectious 
that we may observe women to be infected by 
their husbands, and men by their wives; and 
all their children to die of the same, not only 
from heredity, but from the company of him 
that was first affected." 

By means of modern bacteriological 
methods, the improved compound microscope 
and his own genius, Dr. Koch, after many 
unsuccessful attempts, finally demonstrated 
the microscopic germ called the " tubercle 
bacillus," . which is a rod-like structure, a mi- 
croscopic fungus, so small that it requires 
from eight to twelve thousand placed end to 
end to measure an inch, and 900 of them can 
be placed on the point of a small sewing 
needle, or 4,000,000 on a postage stamp. How 
marvelous the delicacy and power of the 
26 



ITS NATURE AND CAUSE 

modern microscope which will enable us 
easily to detect this infinitesimally tiny germ ! 
In the first place, Dr. Koch, by methods of 
staining and the use of the high-powered 
compound microscope, found this tubercle 
bacillus in every case of tuberculosis, in what- 
ever part of the body the disease existed, and 
in the sputum of consumptives. This he did 
by the examination of the diseased tissues. 
He never found it in other diseases or in 
healthy tissues. He next, by means of the 
methods bacteriologists employ for cultivat- 
ing germs, very like the growing of crops on 
suitable soil, grew a crop of the tubercle ba- 
cilli upon what might be called germ soil, the 
scientific name of which is "media." The 
next step, the most important one of all, was 
to prove that these artificially grown bacilli, 
freed, by a series of transplantations, from all 
products of disease, and all other germs, a 
" pure culture," as it is called, would produce 
the same disease, tuberculosis, whence they 
came. For this purpose, he inoculated a 
large number of guinea-pigs, rabbits, and cats 
with this " pure culture " of tubercle bacilli, 
and also sprayed a solution containing the ba- 
cilli into a large box containing rabbits, 
27 



TUBERCULOSIS 

guinea-pigs, rats and mice, and in every case 
he produced tuberculosis exactly like the 
original disease from which the germs were 
first obtained. Furthermore, he injected into 
hundreds of guinea-pigs and rabbits various 
substances, diseased tissues caused by other 
diseases, etc., and never once produced tuber- 
culosis. This famous demonstration was re- 
peated again and again by other investigators 
and was always corroborated. 

Value of Animal Experimentation 

We hear much in these days of the evils 
of vivisection and experiments upon animals, 
but when one considers the inestimable boon 
conferred upon mankind by the discovery of 
the tubercle bacillus, was not the sacrifice of 
a few animals a thousand times justified? 
" Everything that has a direct bearing on the 
prevention of tuberculosis," says Dr. E. L. 
Trudeau, one of the foremost pioneers and 
investigators in the great movement against 
tuberculosis, " everything that has changed 
mankind's attitude towards it from one of 
apathy and hopelessness when the infectious 
agent which produces tuberculosis was un- 
known and the disease was thought to be ki- 
28 



ITS NATURE AND CAUSE 

herited and always fatal, to the growing hope 
of its ultimate conquest ... we owe to 
animal experimentation.' , 

The new light had at last arisen after so 
many centuries of groping in the dark, the 
true cause of tuberculosis was at last re- 
vealed, and science had triumphed. All 
honor to the great investigator who after 
years of patient and discouraging labor in his 
laboratory had at last succeeded! We extol 
the great captains of war who have waged 
successful campaigns. How much more should 
we esteem those great investigators, like 
Pasteur and Koch, whose victories mean not 
suffering and death, but the preservation of 
life and the conquering of disease. 

Nature of the Tubercle Bacillus 

In investigating the nature of the tubercle 
bacillus, it was found that it did not grow and 
multiply outside of the body, but that it would 
live a considerable time, for weeks or even 
several months, in dark, damp, dirty places; 
that it was readily and quickly destroyed by 
sunlight, and that daylight and fresh air 
would, after a while, kill it, or at least render 
it inactive; that a high temperature, that of 
29 



TUBERCULOSIS 

boiling water, for instance, and certain disin- 
fectants would also destroy it ; but that it sur- 
vived a freezing temperature. 

Having discovered the cause of tuberculo- 
sis, the next inquiry was, how was this germ, 
the tubercle bacillus, conveyed, or, in other 
words, how was tuberculosis caught? Not 
by the mere contact with a person who is suf- 
fering from the disease, as seems to be the 
case in the acute infectious diseases, such as 
small-pox or scarlet fever; nor by the breath, 
as is sometimes erroneously supposed, but by 
the only means by which the bacilli can escape 
from a consumptive person, namely, through 
the expectoration, or in coughing, when tiny 
drops of sputum are thrown out, which ex- 
periments have proved can contain the bacilli. 

Dry Sputum Alone Dangerous 

As long, however, as the tuberculous ex- 
pectoration is mixed with the moist secretions, 
is wet, the bacilli are imprisoned in this moist- 
ure and cannot escape. It is only when the 
moist secretions, the sputum, becomes dry 
that the germs are set free and mix with the 
dust in the air ; then the danger begins. From 
the foregoing it is obvious, then, that a con- 
30 



ITS NATURE AND CAUSE 

sumptive who does not have any expectora- 
tion, as is not infrequently the case in the 
very early stages of the disease, can give out 
no bacilli and consequently is not a source of 
any danger. It also follows that when all the 
expectoration is destroyed before it becomes 
dry, there is again no danger, and also when 
the consumptive holds a cloth or some article 
before his mouth when coughing, there are 
no tubercle bacilli thrown out into the air. 

How to Control the Disease 

The way of the prevention and control of 
the disease would seem plain and easy, or it 
would be easy if we could always control the 
consumptive. This, however, alas! is easier 
said than done, for we have to deal with all 
sorts and conditions of consumptives, some 
ignorant, some careless, some wilful, and some 
who do not know that they are suffering from 
the disease. It is only by education, constant 
watchfulness, the prevention of indiscrimi- 
nate spitting, and in many cases by the removal 
to a hospital, and thus isolating the consump- 
tive, that we can ever hope to control the 
disease. It can be done, however, and great 
progress has already been made. It all de- 
31 



TUBERCULOSIS 

pends upon the energy, determination, and 
contribution of money, effort and time which 
the people are willing to make. 

How many germs must enter one's body be- 
fore tuberculosis is produced we do not know. 
Much, undoubtedly, depends upon what we 
call the susceptibility of the individual. So 
far as we can judge from experience, it takes 
a good many germs and a considerable time 
to become infected. In many cases it is be- 
lieved that the bacilli remain in the body for 
years all unknown, and without causing any 
symptoms, and then, upon a favorable occa- 
sion, when the individual, from some depress- 
ing influence, like over-work, some disease, 
such as an attack of influenza, some excess, 
etc., becomes susceptible, the latent bacilli 
spring into life and active tuberculosis re- 
sults. It is now a generally accepted theory 
that most human beings contract the infection 
of tuberculosis in childhood. 

A "House Disease" 

Observation, again, has taught us that the 
disease for the most part is contracted by 
long and close intimacy with a person suffer- 
ing from it, and who does not properly de- 
stroy his sputum before it becomes dry; 
hence, we call consumption a " house disease," 
32 






ITS NATURE AND CAUSE 

for it so often happens that when one mem- 
ber of a household is suffering from the dis- 
ease, others in the family contract it. If it 
is the father or mother who has tuberculo- 
sis, some of the children are often found to 
be suffering from it. Again, it is not of in- 
frequent occurrence that a workman who, day 
after day, pursues his occupation in close 
intimacy with a fellow-workman who is a 
consumptive and who is careless in the dis- 
posal of his sputum, contracts tuberculosis. 

A momentary exposure to an atmosphere 
containing bacilli is probably not a source of 
danger. There must be a longer exposure 
than that. There is an erroneous impression 
that the tubercle bacilli are so universally dis- 
tributed that we are exposed to them every 
day and everywhere, as a lawyer once re- 
marked to a physician on the witness stand: 
" I suppose there are germs of tuberculosis 
all about this court room." On the contrary, 
researches upon this point all tend towards the 
conclusion that in rooms which are clean and 
in which the atmosphere is quiet, there are 
no bacilli floating about. 

Why, then, one might pertinently ask, do 
we require such stringent measures against 
33 



TUBERCULOSIS 

indiscriminate spitting upon the sidewalks and 
in public places and vehicles? Because, if 
even-body expectorates upon the sidewalk 
there is sure to be someone who is suffering 
from tuberculosis, and the passer-by can 
easily earn- some of the infected sputum into 
his house on his garments or his footwear. 
Children play upon the floor, babies creep 
on the floor, and they frequently put their 
fingers in their mouths; thus they may be- 
come infected. 

How Bacilli Enter the Body 

The next question, and one that is not yet 
settled, is, through what channels the bacilli 
enter the body: do we breathe in the germs, 
take them into the digestive tract through con- 
taminated food, or drink them in infected 
milk? So far as experience and experiment 
permit us to say, the bacilli gain entrance into 
the body through (i) inhalation, breathing 
them into the lungs, and through (2) in- 
gestion, taking them into the stomach and in- 
testinal tract with the food. Some authorities 
think one way is the more frequent and some 
the other. In the author's opinion the ex- 
perimental evidence seems to be greatly in 
34 



ITS NATURE AND CAUSE 

favor of the inhalation method of infection. 
Practically it makes but little difference which 
is the more common way by which the bacilli 
enter the body, for if the tuberculous sputum 
is destroyed before it becomes dry and gets 
into the atmosphere there can be no danger 
of infection by either way. There is also a 
third channel through which the bacilli may 
enter the body, and that is through the skin 
when it is broken, or through a wound. This 
is called the inoculation method. A person 
with a wound upon his finger, for example, 
may handle tuberculous tissue or sputum and 
through the wound become infected with the 
disease. This form of infection happens so 
rarely, however, that it may be disregarded in 
the consideration of the subject. 

Infected Milk 

Milk has been mentioned as a source of in- 
fection, for when it is obtained from tuber- 
culous cows it is not infrequently found to con- 
tain the bovine tubercle bacilli. It was formerly 
supposed that milk was a common carrier of 
infection, and that children whose diet con- 
sists principally of this substance often be- 
come infected in this way. Many health au- 
35 



TUBERCULOSIS 

thorities in cities required dairy herds to be 
" tested," as it is called, by tuberculin, which 
almost invariably proved the presence of tuber- 
culosis when it existed. At the present time 
there is much difference of opinion among 
investigators as to whether or not the kind of 
tuberculosis from which cows and other ani- 
mals suffer can be conveyed to human beings. 
Koch, the discoverer of the human bacillus, 
has, from his investigations, concluded that it 
is an uncommon occurrence for the "bovine 
bacillus," the germ which produces tubercu- 
losis in cows and cattle, to produce the disease 
in man. Other able investigators have come 
to a different conclusion, and a few believe 
that milk containing the " bovine bacillus " 
is the principal source of infection. So the 
question remains unsettled at the present time. 
It is generally believed, however, that gland 
tuberculosis in children, called scrofula, is 
caused by the bovine bacillus. 

So long, however, as the possibility exists 
of infection through milk, the only safe 
method to pursue is to continue the precau- 
tions already adopted, of testing all cows peri- 
odically whose milk is used for domestic pur- 
poses, and to maintain a rigid milk inspec- 

36 



ITS NATURE AND CAUSE 

tion. At the great International Congress on 
Tuberculosis held in 1908 in Washington, the 
following resolution upon this point was 
adopted : " Preventive measures must be con- 
tinued against bovine tuberculosis, and the 
possibility of the propagation of this to man 
should be recognized." 



37 



III. TUBERCULOSIS A CONTAGIOUS 
OR INFECTIOUS DISEASE: WHAT 
THIS MEANS 



What is a I 



What is a Contagious or Infectious Disease? 

OTH of the terms contagious and 
infectious are commonly used 
interchangeably and practically 
mean the same thing. They are 
applied to diseases which are con- 
veyed from one person to another by means 
of some substance or germ, known or un- 
known, either directly by contact with the 
person or germ or through the medium of 
something which has become infected by the 
individual who is suffering from the con- 
tagious disease, whatever it may be. Thus, 
for example, clothing, the furnishings of a 
room, or some article used by the infected 
person, may receive the infectious material or 
germs and anyone who handles these articles 
may in turn contract the disease. Small-pox 
is a familiar example of this form of con- 

38 



A CONTAGIOUS DISEASE 

tagion. Mosquitoes, flies, and other in- 
sects may also be the medium through which 
contagious or infectious diseases are con- 
veyed : thus, a peculiar kind of mosquito car- 
ries the infectious material of yellow fever in 
its body, and flies carry the germs of typhoid 
fever and other diseases. 

Acute Infectious Diseases 

When one speaks ordinarily of infectious 
or contagious diseases he has in mind those 
which are acute and occur in a few days 
after an exposure to them, such as scarlet 
fever, measles, whooping cough, or diph- 
theria. The relation of cause and effect is 
so obvious and the effect follows so closely 
upon the cause, that one is impressed with 
the fact, and, quite naturally, when he hears 
the word contagion, thinks only of this acute 
form of infection. The acutely contagious 
diseases may be contracted by a short expo- 
sure to them: thus, for example, a child who 
comes in contact with another who is suffer- 
ing from scarlet fever or measles, even though 
it may be for a very short time, often contracts 
the disease if it is in a susceptible condition, 
or has not gained immunity from a previous 
39 



TUBERCULOSIS 

attack. We therefore isolate persons who 
have acute infectious diseases for the protec- 
tion of others, and when they have recovered 
we disinfect the sick room for fear that in- 
fectious germs may be lurking about the fur- 
niture or walls of the room. 

With many, if not most of the acute in- 
fectious diseases, we do not know how the 
infection is given off or how it enters the 
body of another person. Consequently, we 
take great care to avoid those suffering from 
such diseases. Ignorance of the cause of evil 
always makes one more apprehensive regard- 
ing it. We fear, often unduly, the enemy 
whose method of attack and of inflicting in- 
jury we are ignorant of. 

Chronic Contagious Diseases 

Besides the acute contagious disease, there 
are also chronically contagious ones, of which 
leprosy and tuberculosis are the best examples. 
Such diseases, although contagious or infec- 
tious, are not conveyed through a momentary 
exposure to them; but is only by long con- 
tact or intimate, continued association with 
individuals suffering from them that we be- 
come infected, and then, probably, only when 
40 



A CONTAGIOUS DISEASE 

we are in a so-called susceptible condition. 
We see, then, that there is a very great differ- 
ence between the two kinds of contagious dis- 
eases — the acute and the chronic. There is 
very little, if any, fear that we shall contract 
the latter — the chronic contagious diseases — 
by a momentary exposure to their infection. 

In the case of tuberculosis, we are not in 
ignorance of the way in which the infection 
is given off or how it is conveyed to another, 
as is the case with most of the acute infec- 
tious diseases. We know that the sputum is 
the only way by which a tuberculous person 
can infect another, and then only when it is 
allowed to become dry before it is destroyed, 
or when a consumptive does not hold some- 
thing before his mouth when he coughs; we 
need have no fear then of a clean consump- 
tive, one who properly and safely disposes of 
his sputum. 

In sanatoria or hospitals for the tuberculous, 
it is a rare occurrence for the physicians or 
attendants to contract the disease, because 
strict precautions are observed in destroying 
the sputum. The dust has been examined 
in such institutions and no tubercle bacilli 
have been found in it unless some patient has 
4i 



TUBERCULOSIS 

been neglectful of the rules in regard to 
properly disposing of the sputum. On the 
other hand, Cornet, a German physician, and 
many other investigators have found in the 
dust of rooms occupied by unclean consump- 
tives, particularly in rooms which were dark 
and damp, the tubercle bacilli, even days or 
weeks after the consumptive had died or been 
removed from the room. Cornet's conclu- 
sions are of importance in discrediting the 
popular opinion of the ubiquity of the tubercle 
bacillus. He says : " The tubercle bacillus is 
found, as a rule, only in places in which an 
uncleanly consumptive maintains himself; 
otherwise, it occurs but rarely." 

This fact is of vast importance also in our 
efforts to control and prevent the disease, for 
it shows us that our main work must be in 
the home of the consumptives. When viewed 
from the standpoint of prevention, the protec- 
tion of the family of the consumptive is of 
far greater importance to the community than 
the care or even the cure of the consumptive 
himself. If the consumptive is not or cannot 
be made to safely dispose of his sputum, he 
must be removed to a hospital and his chil- 
dren must be kept constantly under observa- 
42 



A CONTAGIOUS DISEASE 

tion, and in some cases removed from their 
homes. 

" Consumption Terror " 

It is unfortunate that the terms contagious 
and infectious have been applied to tuberculo- 
sis, as true as it is ; " communicable " would 
have been a better term, for the distinction 
in the conditions of infection between an 
acute and chronic contagious disease, as has 
been pointed out above, is not clearly recog- 
nized in the popular mind. Because tubercu- 
losis is called contagious, it is often classed 
in the same catagory as the acute contagious 
diseases, and the same fear has been aroused 
as in regard to the latter diseases. This fear 
has led to a great injustice being done the 
poor consumptive: he has been shunned and 
treated as if he were a leper, or suffering 
from an acute infection. This " consumption 
terror," as it has been called, has not only 
been the means of inflicting great hardships 
and suffering upon the consumptive himself, 
but has seriously interfered with the general 
work of prevention. 

For instance, it has not infrequently hap- 
pened that the establishment of sanatoria or 
43 



TUBERCULOSIS 

dispensaries for tuberculosis has been op- 
posed or rendered impossible by those living 
in the neighborhood on account of this unrea- 
sonable fear, whereas, carefully collected sta- 
tistics have shown that the mortality from 
tuberculosis has been reduced in places where 
sanatoria have been established. For exam- 
ple, in Goerbersdorf and Faulkenstein, where 
several sanatoria have existed for many years, 
the death rate from consumption has mark- 
edly decreased. This has been brought about 
by the example set by the sanatorium of a 
high standard of sanitation and hygiene, which 
was imitated by those living in the neighbor- 
hood. Again, it is often difficult for a con- 
sumptive and his family to obtain a dwelling 
or a tenement on account of the " consump- 
tion terror," or a consumptive workman may 
lose his position through the " consumption 
terror " on the part of his fellow-workmen. 

An incident was recently related of a con- 
sumptive tailor who expectorated upon the 
floor of the shop, about him, although he 
knew better, for fear that he would lose his 
position if he was observed to use a proper 
receptacle for his sputum. In many hotels, 
particularly in health resorts, consumptives 

44 



A CONTAGIOUS DISEASE 

are not received under any condition, and 
are often almost cruelly turned away. This 
is not so much the fault of the proprietors 
as the unreasoning fear of the guests. Even 
consumptives who have been discharged 
from the sanatorium with their disease cured, 
often find it difficult to obtain a position if 
the fact is known. The unfortunate con- 
sumptive often suffers more from this heart- 
less, ignorant, cowardly fear than he does from 
the disease itself. 

The Only Way Consumption is Conveyed 

It is therefore of the highest importance 
that everyone should remember that it is only 
the expectorated sputum of the consumptive, 
and that alone, which contains the infecting 
material, the tubercle bacilli, and which can 
carry the disease from one person to another, 
and that when this sputum is destroyed before 
it becomes dry, the consumptive is harmless. 
Furthermore, no one need fear that he will 
become infected by coming in contact with a 
consumptive for a short time ; or staying with 
a consumptive who does not cough, or who 
properly disposes of his sputum. It may well 
be repeated again that to be infected by tuber- 
45 



TUBERCULOSIS 

culosis, one must for a considerable time live 
or work continuously with a consumptive who 
coughs and who is not careful in the dispo- 
sition of his sputum. The Swedish National 
Anti-Tuberculosis Association has thus admi- 
rably summarized the evils of the " consump- 
tion terror " : 

The " consumption terror " paralyzes the 
struggle against tuberculosis. 

The " consumption terror " prevents con- 
sumptives from taking care of themselves. 

The " consumption terror " renders all 
measures against tuberculosis more difficult. 

The " consumption terror " facilitates the 
spread of infection. 

The " consumption terror " causes us to 
overlook the real danger. 

The " consumption terror " is a sign of 
shameful cowardice. 

The " consumption terror " causes cruel be- 
havior to consumptives. 

The " consumption terror " is an enemy to 
society that must be opposed. 



46 



IV. INHERITANCE AND IMMUNITY 

OR. HOLMES somewhere wittily 
says that in order to produce a 
high type of human being, " a 
man should be careful in the 
selection of his ancestors." The 
work must have its beginning with the grand- 
parents or great-grandparents. In other 
words, he evidently meant to say that inherit- 
ance played a very important part in the 
moral, physical, and intellectual welfare of 
a man. Inheritance does, undoubtedly, exer- 
cise a very material influence in shaping one's 
career and character, as the new science of eu- 
genics teaches, how much, no one knows ; but 
we often ascribe to it many defects in the 
moral and physical condition of a person, for 
which it is in no way responsible and which 
are within his own control. So it has hap- 
pened with regard to diseases, the cause and 
origin of which we were ignorant. Either 
" providence " or inheritance were often 
made the scapegoat for many diseases which 

47 



TUBERCULOSIS 

afflicted mankind, the real cause of which was 
their own ignorance or disregard of nature's 
laws. It was so with regard to tuberculosis. 
The universal belief was, that it was an in- 
herited disease, and even now, with the knowl- 
edge of its cause, one frequently hears the old 
inheritance doctrine asserted, such is the te- 
nacity of old and long-entertained ideas. 

The Old Idea Versus the New 

It was very natural, however, that in the 
dark days of tuberculosis, as we might call the 
time before the discovery of the true cause, 
one should thus explain the frequent occur- 
rence of several cases of the disease in the 
same family, when one member after another 
succumbed to it. " How else can this be 
explained," one said, " except by inherit- 
ance? " 

With the discovery of the fact that tuber- 
culosis was an infectious or communicable 
disease caused by a germ, all was made clear 
and the inheritance theory became untenable. 
Not knowing that the fatal germ, the tubercle 
bacillus, lurked in the sputum of a consump- 
tive, no care was taken to destroy it before 
it became dry, and so the disease was com- 

48 



INHERITANCE AND IMMUNITY 

municated to others who were in constant at- 
tention upon, or in intimate, long-continued 
relation with, the consumptive. 

What was ignorantly regarded as inherit- 
ance was simply infection. The disease was 
caught through the germs, not inherited, and 
so, alas ! it went on being communicated, until 
Koch's discovery removed the veil of igno- 
rance and enlightened the world as to the true 
nature of the disease, and the danger from 
the dried sputum. 

What is "Inheritance"? 

Still, however, we retain the word inherit- 
ance, with regard to tuberculosis, but with a 
different meaning. We say now, that a ten- 
dency to it, or a predisposition to it, is inher- 
ited, that when a person has tuberculosis " in 
the family," when, for example, his father 
or mother has died of it, he may have inher- 
ited in consequence a tendency to the disease 
and is more likely to contract it when exposed 
to the bacilli. 

The occurrence of tuberculosis in the fam- 
ily of one suffering from the disease, either 
on the father's or mother's side or on both, is 
so frequent that the inheritance of a predispo- 
49 



TUBERCULOSIS 

sition to the disease would seem to be evident. 
It must be remembered, however, that the op- 
portunities for contracting the disease in a 
household where some member is suffering 
from it are naturally greater than when no 
such case exists, for, unfortunately, there are 
still many homes where the dangers from the 
dried sputum are still not fully realized. What, 
therefore, we ascribe to inheritance, is, un- 
doubtedly, in many cases only the result of 
greater opportunities for infection. 

It may be that a special susceptibility to 
tuberculosis is really inherited, but, on the 
other hand, the true fact may be only this, 
that the children of consumptive parents, espe- 
cially of a consumptive mother, are not as 
robust and resistant as those whose parents 
were well and strong when they were born, 
and hence, they are more susceptible to any 
infectious disease, including tuberculosis, and, 
furthermore, if the tuberculous parent is liv- 
ing with the children in the same household, 
the opportunities for infection are greater, as 
has been said. 

The practical lesson from all this is, that 
weakly children should receive especial atten- 
tion and very effort made to build up their 
50 



INHERITANCE AND IMMUNITY 

strength and health and increase their resist- 
ing - power to disease, and, secondly, they 
should be removed from sources of infection. 
A consumptive mother should not nurse her 
baby, or children should not be permitted to 
live in intimate association with consumptive 
parents or relatives. Moreover, all the chil- 
dren from a household where a case of tuber- 
culosis exists, should receive a careful exam- 
ination from time to time. Where this has 
been done, as is now the custom in tubercu- 
losis dispensaries, unsuspected cases have been 
discovered, and when the disease is detected 
and treated in its beginning, as will later be 
shown, the cure will generally follow. 

Predisposition and Immunity 

We now also use the word " predisposition " 
in still another sense. We speak of an " ac- 
quired predisposition," which means that an 
individual may by various unwholesome influ- 
ences of living and unfavorable environment 
(which will be considered more at length in 
the next chapter), so reduce his resistance to 
disease that his system readily yields to infec- 
tious germs of any kind when exposed to them, 
and among them, to the germs of tuberculo- 
sa 



TUBERCULOSIS 

sis. Such an individual, we say, has, by his 
faulty method of living, acquired a " predis- 
position " to the disease. He has lowered his 
resistance either permanently or temporarily. 
Upon this fact of lowered resistance is based 
the modern method of treatment of tubercu- 
losis, which consists, in brief, in placing the 
patient under such favorable conditions of 
living that his system will regain this lost re- 
sistance to disease and re-establish what we 
call his natural " immunity." 

Every individual possesses within his body 
to a greater or less degree a natural tendency 
to resist disease. This inborn tendency we 
call one's natural " immunity." When any 
poisonous or infectious germ enters the body, 
a defensive army is set in operation within 
the body which endeavors to destroy or limit 
the influence of such germs, and the activity 
of this opposing army depends upon the degree 
of immunity the individual possesses. 

The white blood cells called " leucocytes " 
possess the power to a greater or less extent 
of destroying infectious germs. This they 
do by enveloping or eating them up, so to 
speak. This process is called " phagocytosis " 
and was first demonstrated by a famous 

5 2 



INHERITANCE AND IMMUNITY 

French investigator, Metchinkoff, who is the 
successor to the more famous Pasteur. 

It is a very wonderful provision of nature 
that when any infectious material enters the 
body, the number of leucocytes or white blood 
cells are generally increased. Nature calls 
out her reserves as the danger arises or in- 
creases. When, in any infectious disease, we 
find a large increase in these scavenger cells, 
the leucocytes, we say the fight is going on 
well, but, when, on the contrary, there is no 
increase, we are fearful of the result. Pneu- 
monia is a good illustration of this process. 
When by microscopical count the blood shows 
few leucocytes, we give a grave prognosis. 
Further investigation has shown that other 
cells and fluids of the body also assist in this 
work of destroying or rendering inactive in- 
fectious germs, and there still remains much 
to be learned about all the causes of natural 
immunity. 

Antitoxins and Vaccines 

As is well known, we can also inject into 

the body various antitoxins or vaccines which 

will further increase the defensive barriers 

of the body and neutralize or destroy the 

53 



TUBERCULOSIS 

toxins or poisons produced by the various 
specific bacteria or germs, will produce an 
artificial immunity. This we do with success 
in diphtheria by use of the well-known diph- 
theria antitoxin, and in tetanus, or " lock- 
jaw," with more or less success by the tetanus 
antitoxin, and in cerebro-spinal meningitis by 
its peculiar antitoxin. 

The great goal toward which the modern 
medical world is now striving is to discover 
antitoxins or vaccines for all infectious 
diseases, so that, for example, when pneu- 
monia, scarlet fever, and other diseases, caused 
by specific bacteria or germs, occur, we may 
vaccinate or inject into the body the proper 
antitoxin or vaccine for each disease and thus 
cut short its course, just as we now success- 
fully do in diphtheria. Many attempts have 
been made to discover an efficient antitoxin 
or vaccine for tuberculosis, but as yet it has 
not been found. Maragliano, a celebrated 
Italian physician, thought he had discovered 
such an antitoxin or serum, and so did Yon 
Behring, the man who discovered the diph- 
theria antitoxin. Dr. Trudeau also, the great- 
est investigator in this country upon tuber- 
culosis problems, has, for many years, been 
54 



INHERITANCE AND IMMUNITY 

working in this direction and so have many 
others. None of these men, however, has as 
yet produced an antitoxin which can in any 
degree do for tuberculosis in the human being 
what the antitoxin does in diphtheria. Still, 
however, these illustrious investigators pa- 
tiently work on with a host of others, and we 
may hope that eventually success will come and 
the true tuberculosis antitoxin be discovered. 
" Tuberculin," a sort of serum or anti- 
toxin made from the tubercle bacilli, origi- 
nally prepared by Koch, was at first thought 
to be a genuine antitoxin for tuberculosis, and 
when Dr. Koch first gave it to the medical 
public, consumptives flocked to Berlin to be 
treated with the marvelous specific, as it was 
then supposed to be, and physicians from all 
over the world were besieging Dr. Koch for 
some of the precious substance for their con- 
sumptive patients. Hope was high that at 
last the great physician who had discovered 
the cause had also discovered the remedy. 
Alas ! both physician and patient were doomed 
to cruel disappointment. The tuberculin did 
more harm than good, for many lives were 
sacrificed in an overzealous use of it in almost 
poisonous doses. The awakening soon came 
55 



TUBERCULOSIS 

and the supposed specific, tuberculin, was 
abandoned as suddenly as it had leaped into 
favor. Subsequent experience, however, has 
apparently shown, that, employed in infinitely 
small doses and with proper cases, it has more 
or less value when used in connection with 
the open-air treatment. Its effect seems to 
be to increase the resisting power of the indi- 
vidual. 

Tuberculin, when used with animals, seems 
to give immunity to the tubercle bacillus. 
Koch, Dr. Trudeau, Von Behring, and others 
have obtained such a result in their experi- 
ments with animals. But it has often been 
found that what has succeeded in animal ex- 
perimentation has failed in human beings, 
although it must not be forgotten that, on 
the other hand, animal experimentation has 
led to many discoveries which have conferred 
lasting and great benefits upon mankind. 

Immunity in Acute Diseases 

It has been thought and there are some facts 
which appear to corroborate the belief that 
sometimes one receives from parents who have 
died of tuberculosis an immunity to the 
disease. If this is really so, it unfortunately 

56 



INHERITANCE AND IMMUNITY 

happens but rarely. With the acute infectious 
diseases, however, like whooping cough, mea- 
sles, etc., a single attack generally produces 
an immunity to subsequent attacks of the same 
disease. But this, as we know, is not the case 
with the chronic infectious diseases. How 
fortunate it would be if, having recovered 
from tuberculosis, one was assured, in conse- 
quence, that he would never suffer from it 
again and there is some evidence to show that 
a tuberculous focus somewhere in the body or 
a slight tuberculous infection does produce a 
partial immunity. At the present time, then, 
we can only strive to increase the natural re- 
sisting power, the " natural immunity " of the 
individual, and hope that future investigations 
and research may bring us the much-desired 
antitoxin or vaccine for tuberculosis. 



57 



V. THE SEED AND SOIL 

^ffiUftk ) WO things are necessary in order 
m £*\. t0 contract a contagious disease, 
Hl 1 whether it be an acute or a 

^^j^3F chronic one: the one is the pres- 
ence of the infection — the germs 
of the special disease — and its entrance into 
the body in a sufficient quantity ; and the other 
is a receptive state in the individual. Not 
everyone who is exposed to an acute infec- 
tious disease contracts it, as we know, and, 
likewise, not everyone who is exposed to the 
infection of tuberculosis — the tubercle bacilli 
— becomes a victim to it. Neither, on the 
contrary, can anyone, however receptive his 
condition may be, contract tuberculosis, or, 
indeed, any contagious disease, unless he is 
exposed to the germs of that disease. No 
matter how susceptible the individual or how 
little his resistance, how unfavorable his en- 
vironment or how unhygienic the conditions 
may be, if the specific micro-organism is ab- 
sent tuberculosis is impossible. 

58 



SEED AND SOIL 

Two Things Necessary to Contagion 

Some years ago there was no tuberculosis 
in Iceland, and yet the inhabitants of this 
island lived under the most unfavorable and 
unhygienic conditions. The winter was long 
and dreary, and the sky cloudy and the atmos- 
phere filled with dampness. Their dwellings 
were small, dirty, dark, and unventilated, each 
person having scarcely ninety-nine cubic feet 
of air to breathe. These abodes were filled 
with foul-smelling vapor rising from the de- 
bris of fish lying about the door, and the smoke 
from dried dung which constituted their fuel. 
Their food consisted mainly of dried fish which 
had begun to putrify, a preparation of milk 
called " sky," large quantities of rancid but- 
ter, and sour whey mixed with water; they 
also drank large quantities of alcohol. Their 
occupation was one of exposure in fishing, 
bird hunting, and sheep and cattle herding. 
Their feet were constantly wet. In spite of 
this extraordinarily unwholesome and perni- 
cious condition of existence, no case of pul- 
monary tuberculosis existed. The suscepti- 
ble condition was undoubtedly present, but the 
tubercle bacillus was absent. Whenever any 
of the Icelanders migrated to the mainland 
59 



TUBERCULOSIS 

of Denmark tuberculosis was extraordinarily 
frequent among them, as one would expect, 
for then occurred the union of the favorable 
soil, the susceptible condition, produced by the 
unhygienic life of the Icelander, with the 
tubercle bacillus existing in Denmark. 

We must have, then, both good seed and a 
favorable soil, a soil suited to the growth of 
the seed, in order that a crop may be produced 
and come to maturity. The seed must fall 
upon " good soil," as in the parable of the 
seed and the sower. 

The Favorable Soil 

What the seed is in tuberculosis we have 
already learned: it is the tubercle bacillus. 
How it is obtained, we also know: it comes 
from the sputum of an individual suffering 
from the disease. We have now to consider 
the favorable soil and how it is produced, or, 
in other words, what influences or conditions 
render one receptive to the tubercle bacillus. 
Although we cannot say in any individual 
case what especial unfavorable condition may 
render him receptive, for we have no means 
of measuring the subtile something which we 
call one's resistance to disease, still observa- 
60 



SEED AND SOIL 

tion and experience have taught us in a gen- 
eral way under what conditions this receptive 
state to tuberculosis is most likely to occur. 
In studying many cases of tuberculosis, cer- 
tain influences in the previous or present life 
of the consumptive, or in his surroundings, 
have been so frequently found to be present, 
that we can infer with a great probability of 
truth that these influences must have been 
important factors in preparing the favorable 
soil and in rendering the individual suscepti- 
ble to the infecting germ, the tubercle ba- 
cillus. 

In general, we have found that anything 
which impairs the general health of a person 
may be a predisposing cause to tuberculosis. 
In the first place, certain diseases from which 
the patient has previously suffered appear to 
be predisposing causes. Such are whooping 
cough, bronchitis, influenza, popularly known 
as the " grippe," measles, and, to a less extent, 
scarlet fever, typhoid fever, pleurisy, diabetes, 
syphilis and, perhaps, others. It must be said* 
however, in this connection, that probably in- 
some cases where these diseases have occurred,, 
the tuberculosis was already present in a latent 
condition, and the disease rendered it active. 
61 



TUBERCULOSIS 

This seems to be especially the case with influ- 
enza. The practical lesson to be drawn from 
this is that especial attention should be given 
to those convalescing from the acute diseases 
mentioned above, so that a thorough recovery 
may ensue and one's normal resisting power 
be established as soon as possible, and that one 
should avoid close association with those suf- 
fering from influenza or a " cold." 

In children enlarged tonsils and the growth 
in the back of the nose called " adenoids " 
afford a favorable local soil for the tubercle 
bacilli, and they have been found in these 
places. Moreover, the " adenoids " by ob- 
structing the nose, and the tonsils by narrow- 
ing the passage into the lungs render respira- 
tion inadequate, and in consequence the chest 
fails of its full development. The whole body 
suffers from the defective aeration and be- 
comes less resistant to the tuberculosis infec- 
tion. This subject will be again referred to 
when speaking of tuberculosis and the child. 

The " Neglected Cold" 

The so-called " neglected cold " is often 
adduced as a frequent exciting cause of pul- 
monary tuberculosis, and when one considers 
the enormous frequency of colds in northern 
62 



SEED AND SOIL 

climates during the winter season, such would 
seem to be the fact. In 2700 supposedly well 
men examined by the writer 41.4 per cent 
complained of colds in the head or throat. 
It is undoubtedly true that what is often called 
a " cold " is the real beginning of tuberculosis : 
one begins to cough from the irritation caused 
by tuberculosis, and therefore he thinks, quite 
naturally, that " it is a cold." Nevertheless, a 
simple cold neglected may open the door for 
the tubercle bacillus to enter. Modern bacte- 
riological studies have taught us that all colds 
or catarrhs are caused by infection by some 
germ or combination of germs ; but " cold " 
germs, like tuberculosis germs, must have a 
suitable soil, an exciting cause. What are 
some of these causes? Impure air, dust, ex- 
treme and sudden alterations of temperature, 
excessive indoor temperature, dry heat, lack 
of physical exercise, and inadequate respira- 
tion, neglect of daily cold bathing of the 
throat and chest, an excessive amount of 
clothing, insufficient sleep and rest, mouth 
breathing, excess in eating and drinking, con- 
stipation. These neglected colds or fre- 
quently recurring catarrhal affections " may 
form predisposing causes," says Dr. Webber, 
" either by producing sore places in the lining 

63 



TUBERCULOSIS 

membrane of the respiratory tract, called the 
mucous membrane, and thus allowing the 
bacilli to settle, or by weakening the cells of 
this mucous membrane and their ciliary (pro- 
tective) action," — for these cilia are tiny, hair- 
like bodies, constantly in motion, and like a 
street sweeper, constantly sweeping out all 
impurities from the respiratory passages, — 
" or by causing imperfect breathing from un- 
consciously avoiding deep inspiration in order 
to avoid coughing, or by weakening the nutri- 
tion and energy of the whole system." 

Overcrowding as a Cause of Tuberculosis 

All the innumerable evils of unsanitary liv- 
ing, which depress one's vitality, are obviously 
potent influences in preparing the favorable 
soil for the tubercle bacillus. Overcrowding, 
as in the tenements of the poor in large cities, 
is everywhere recognized as one of the great 
predisposing causes. Thus, in Paris, where 
so much pulmonary tuberculosis exists and 
where more than three-fourths of all the fami- 
lies live in three rooms or less, it has been 
found that the number of cases of tuberculosis 
increases as the number of rooms in a tene- 
ment decreases. In London, statistics show 
64 



SEED AND SOIL 

that the death rate from tuberculosis varies 
according to the number of persons in a room. 
In the famous so-called " lung block " in New 
York City, a great block of the worst kind of 
tenements, densely inhabited, very many cases 
of tuberculosis were found to exist. In asy- 
lums, prisons, and other institutions where 
large numbers of human beings are kept 
in close contact, pulmonary tuberculosis 
was frequently the most common disease 
among the inmates, and sometimes produced 
an almost epidemic mortality. In recent years 
especial provision has been made in many 
asylums and prisons for removing the con- 
sumptive inmates and placing them under 
open-air conditions of living in much the 
same way as in a sanatorium. Of course, 
overcrowding acts in two ways; greater op- 
portunities of contracting the disease are af- 
forded, for there are quite sure to be some 
consumptives present, and at the same time 
the health of all is impaired by the unwhole- 
some conditions incident to the overcrowd- 
ing. 

Whenever, in the remote past, tuberculosis 
first originated, it was probably coincident 
with the concentration of human beings in 

65 



TUBERCULOSIS 

small areas, crowding" together, and with the 
building of closed places of abode, for, as we 
have seen, it is, for the most part, a disease 
of indoor life, a " house disease." In the. 
evolution of civilization, we have reversed 
the natural order of things, and instead of 
regarding indoor life the exception, we have 
made it the rule; and in northern latitudes 
we spend the greater part of the twenty-four 
hours under artificial conditions, where we 
breathe air as devoid of moisture as the Desert 
of Sahara, and heated to a temperature of 70 ° 
or more. Such hot, dry air impairs the pro- 
tective apparatus of the upper respiratory 
tract, and bacteria can gain a more ready en- 
trance. We have become so accustomed to 
this abnormal, constant indoor life, that its 
dangers are lost sight of, but they are none 
the less real, and especially menace those of 
deficient vitality, and gradually lower one's 
resisting power to disease. 

Fresh Air and Sunshine 

Absence of fresh air and sunshine is an- 
other powerful predisposing cause; and this 
is a condition not always confined to the tene- 
ment houses of the poor, but also not infre- 
66 



SEED AND SOIL 

quently existent in the apartments of the well- 
to-do. In the tenements of New York City 
there were found to be 350,000 dark interior 
rooms with no windows admitting* fresh air 
and sunshine. Fresh air is as necessary as 
food. Indeed, it is food for the blood, which 
is the elaborated food of the body. Fresh 
air stimulates and maintains in a vigorous 
state the lung tissue itself. If impure, dirty 
air was as visible as dirty water, we should 
be less ready to bathe our lungs in it, in our 
houses and in public places and in vehicles; 
and we should to a far greater degree recog- 
nize its dangers. 

Sunshine is equally necessary for a health- 
ful existence, and without it one becomes 
sickly and pale like a plant in a cellar. An 
instance is related of a family, consisting of 
a man, his wife and five children, previously 
perfectly healthy, who moved to Paris from 
the country and lived in a cellar. The chil- 
dren and mother died quickly of tuberculosis, 
which first attacked the children: the father, 
who worked in the open air, alone escaped. 
" Where sunlight enters not, there the physi- 
cian goes," says the old proverb. Sunshine 
will destroy the tubercle bacilli in a short time. 

67 



TUBERCULOSIS 

Sunshine brings cheerfulness of. spirits and 
invigorates the body, and its beneficent influ- 
ence is probably far greater than we can as 
yet estimate. At Rollier's sanatorium in Ley- 
sin, Switzerland, children with bone, joint and 
gland tuberculosis are exposed naked for hours 
to the direct rays of the sun, and with re- 
markably beneficial results. 

Dr. Trudeau's famous experiment with the 
rabbits well illustrates the evil effects of the 
absence of fresh air and sunshine. He inocu- 
lated a number of rabbits with equal doses of 
tubercle bacilli, and then he allowed half of 
them to run free in the fresh air and sun- 
light, while the other half were confined in a 
dark cellar where the sunlight and fresh air 
were excluded. Both sets of rabbits were 
killed at the same time ; those which had been 
allowed to run free had recovered or showed 
only slight disease, while those which were 
confined in the dark place had extensive tuber- 
culosis. 

A member of Nansen's Arctic expedition 
thus describes the alternate influence of dark- 
ness and sunlight upon the mind and body. 
He says : " The last winter in the ice was 
simply awful. We had our fill of the dark- 
ness. We got sleepy and indifferent, and 
shaky on our legs. We were not ill, but weak 
68 



SEED AND SOIL 

and dead beat, and the doctor was anxious 
about our brains. When the day came, with 
the sun, it was like a resurrection for us all. 
We were electrified when we saw him. No- 
body knows how fine the sun looks but those 
who have been six months in darkness. Then 
we came to strength again." 

So long as modern civilization and indus- 
trialism require such constant and almost com- 
plete indoor existence, great care should be 
taken that the fresh air and sunshine have 
abundant access to the house, factory, work- 
shop, and store. How many a poor clerk, book- 
keeper, or shop girl in a department store has 
been and is preparing a favorable soil for the 
tubercle bacillus, by being confined in some 
dark corner in the basement or elsewhere 
where the sun never enters and the contami- 
nated, foul air is never changed by proper 
ventilation! Even the well-to-do, who can 
command the situation, too often forgets the 
invigorating influences of fresh air and sun- 
shine. " He deliberately turns his back upon 
the light of the sun," says Mr. Edward Car- 
penter in his " Civilization — its Cause and 
Cure," " and hides himself away in boxes 
with breathing holes (which he calls houses), 
living ever more and more in darkness and 
asphyxia, and only coming forth perhaps once 

69 



TUBERCULOSIS 

a day to blink at the bright god, or to run 
back again at the first breath of the free wind 
for fear of catching cold ! " 

Evils of Inadequate Respiration 

Inadequate and partial respiration is, in the 
writer's opinion and experience, a frequent 
predisposing cause of tuberculosis, and, in our 
sedentary life, is a very common condition. 
Not only is the resisting power of the lung 
tissue itself diminished, but the aeration of 
the blood, upon which depend so largely all 
the vital processes, is imperfectly performed. 
Full and free breathing strengthens the pul- 
monary tissue, increases its vitality and con- 
sequently its power of resistance to disease. 
In his original state good breathing came 
naturally to man, for he was intended to be 
an active animal — to run and climb, to bend 
and twist his body, to stretch and extend his 
arms, and, in brief, use all his muscles, and 
as long as he followed Nature in this respect, 
his lungs had full play and the respiratory 
muscles were maintained in a state of effi- 
ciency. So-called civilization, or, at least, city 
civilization, has so modified all this, that one's 
life, in a large number of occupations, has 
70 



SEED AND SOIL 

resolved itself into a mental hunt for sub- 
sistance rather than an active bodily one. The 
natural life, with its bodily activity, has be- 
come an artificial one of more or less bodily 
immobility, and what Nature unconsciously 
did to promote and maintain proper breathing 
must now be done by conscious effort and arti- 
ficial methods, such as gymnastics and ath- 
letic exercises and training. 

True, a person might perhaps live in com- 
fortable health in this inactive condition, only 
half-filling and using his lungs, if he were al- 
ways sure of remaining in it, but he never 
knows when an emergency may arise which will 
require the respiration which well-trained lungs 
can only give, be it running for the doctor 
in a case of life or death, swimming to save 
himself in a shipwreck, or exposure to the 
tubercle bacillus when, in addition, the nutri- 
tion happens to be poor or the system de- 
pressed. And, further, the sense of physical 
well-being is much greater when the respira- 
tory tide is full and strong, as the experience 
of all of us can testify after some exercise 
which makes large demands upon the " wind," 
such as running, a game of tennis, or swim- 
ming. As some one has well said, " To 
71 



TUBERCULOSIS 

breathe well means to live well, to live longer 
and to live better." 

Value of Proper Food 

Insufficient and improperly prepared food 
is, again, a recognized predisposing cause of 
tuberculosis, and it requires no argument to 
establish this fact. It is, however, less obvi- 
ous that food, in order to nourish the body- 
properly and enable it to maintain its working 
and resisting efficiency, must consist of the 
proper ingredients and in proper proportions. 
We must have, in the first place, the proteids, 
the most important variety of food, which are 
tissue-builders and repairers of the body, and 
which are furnished by both the animal and 
vegetable kingdoms, examples of which are 
meats of various kinds, milk, cheese, peas, 
beans, etc. Secondly, we must have the car- 
bohydrates, which supply heat and energy, and 
are usually of vegetable origin, such as 
starches, sugar, cereals, bread, potatoes, etc.; 
and, thirdly, fats, which also supply heat as 
well as fat — indeed, they are the most impor- 
tant heat producers. The Esquimaux, who 
require a large amount of body heat to with- 
stand the cold of their Arctic climate, are large 
72 



SEED AND SOIL 

consumers of fats. Fats are obtained both 
from animal and vegetable sources, such as 
the fat of meat, cream, butter, olive, and other 
vegetable oils. It has been found by universal 
experience that a mixed diet of meat, bread, 
milk, eggs, vegetables containing fat and 
sugar in some form, will best furnish these 
essential principles. 

It is well to bear in mind that food must 
not only be nourishing, but be prepared in a 
palatable and digestible form : hence the im- 
portance of good cooking. Dettweiler, the 
head of a famous sanatorium in Germany, 
used to say that his pharmacy was his kitchen, 
so important did he consider the food and its 
preparation in the treatment of his patients. 

Defective Teeth 

Defective teeth are a very real predispos- 
ing cause of tuberculosis; for diseased teeth 
in themselves, as some one has aptly said, 
" become human culture tubes with ideal cul- 
ture mediums for the germs of disease " ; 
they also interfere with nutrition through in- 
complete mastication. When nutrition fails, 
the body's resistance to disease is reduced. 
" Defective teeth," says Dr. Osier, " cause 
73 



TUBERCULOSIS 

more physical deterioration than does alco- 
hol " ; and Professor Jessen of Strassburg de- 
clares that " the tuberculosis question, in addi- 
tion to unhygienic dwellings, insufficient sup- 
ply of air and light, is a question of nutrition, 
and, therefore, a healthy mouth is an essential 
first condition." The practical deduction from 
this is that the mouth and teeth should be 
kept in good condition, and the food thor- 
oughly masticated as the first and perhaps 
most important step in digestion. Good diges- 
tion means good resistance to disease. 

Alcohol Makes the Bed of Tuberculosis 

Excesses of all kinds, particularly in the 
use of alcohol, lower the vitality and prepare 
the favorable soil for tuberculosis. The 
French physicians attribute the great preva- 
lence of tuberculosis in that country to two 
principal causes, overcrowding and the abuse 
of alcohol. Professor Landouzy says that 
" alcohol makes the bed of tuberculosis " ; 
and another French professor, Brouardel, de- 
clares that " alcoholism is, in fact, the most 
powerful factor in the propagation of tuber- 
culosis. The most vigorous man, who be- 
comes alcoholic, is without resistance before 
74 



SEED AND SOIL 

it." In the case of two hundred and thirty- 
two consumptives under the writer's observa- 
tion, 41 per cent, gave a history of the exces- 
sive use of alcohol. Dr. Newsholme, of Eng- 
land, who has made a very exhaustive investi- 
gation of the causes of tuberculosis, says that 
it is fairly clear that there is an excessive 
death rate from consumption among intem- 
perate persons. Physicians have long recog- 
nized the fact that those who use alcohol, even 
moderately, have less resistance to infectious 
diseases; and in the modern treatment of 
tuberculosis, alcohol finds very little place. 

Injurious Occupations 

There are certain occupations which seem 
particularly prone to predispose those who 
follow them, to tuberculosis; this they do 
probably both by their influence upon the 
lung tissue itself as well as upon the general 
health. Those employed where there is much 
dust, such as stone-cutters, knife-grinders, pot- 
ters, dyers, wool-carders, cigarmakers, polish- 
ers, and the like, especially where the work is 
carried on in confined spaces, have always 
suffered a large mortality from tuberculosis. 
It has been calculated that forty thousand or 
75 



TUBERCULOSIS 

more deaths occurred annually in England 
and Wales among those thus employed. Mr. 
Hoffman, the statistician of the Prudential 
Life Insurance Company, in an analysis of 
22,987 deaths from all causes in those engaged 
in dusty occupations, found that the propor- 
tionate mortality from consumption was 28.0 
per cent, of the mortality from all causes at 
ages fifteen and over, while among men in 
agricultural, transportation, and other outdoor 
occupations, the consumption death rate was 
only 9.5 per cent, of the mortality from all 
causes. " If," he says, " the consumption 
mortality in dusty trades could be reduced to 
the corresponding proportion for men in out- 
door occupations," which he believes is possi- 
ble, " a very large number of lives would be 
saved and continue for many years, which are 
now, to a large extent, needlessly wasted." 
Printers, compositors, dressmakers, bakers, 
and those who work where smoke and irritat- 
ing gases are generated contract tuberculosis 
readily. Teamsters and hack-drivers are also 
frequent sufferers from tuberculosis in spite 
of their outdoor life, probably from their ir- 
regularity of living and alcoholism, for it has 
7 6 



SEED AND SOIL 

been observed that employments which are 
associated with temptations to the abuse of 
alcohol have a high death rate from consump- 
tion. 

In certain factories and workshops where 
the employees are crowded together in a con- 
fined atmosphere and when there is an absence 
of sufficient light, tuberculosis is frequent. 
Probably two causes are at work under these 
conditions: In the first place, the vitality is 
lowered by the existing unwholesome influ- 
ences in such workshops, and thus the suitable 
soil is prepared ; and, secondly, there is always 
the danger that some workman may be tuber- 
culous and infect his fellow-workmen if he is 
not careful to destroy or safely dispose of his 
sputum, — the seed is present. The following 
case illustrates this danger : In a small and ill- 
ventilated portion of a counting-house con- 
taining -twenty-two employees there came two 
tuberculous persons, coughing and expecto- 
rating often upon the floor. The employees 
came early in the morning to work, when the 
air of the place was filled with dust from the 
daily sweeping. Within five years thirteen of 
these employees died of tuberculosis. 
77 



TUBERCULOSIS 

Over-Fatigue and Over-Exertion 

Over-fatigue, overwork, and over-exertion, 
as well as insufficient rest and sleep, again 
lower one's resisting power to disease and help 
prepare the suitable soil. " To my mind," 
says Dr. Burton-Fanning, " there are few 
causes more powerful to determine the out- 
break of pulmonary tuberculosis than physical 
over-exertion." " I have been struck," he 
continues, " by the frequency with which con- 
sumption attacks men who have distinguished 
themselves in various athletic pursuits. This 
remark particularly applies to such sports as 
tax the power of endurance, such as long- 
distance bicycle riding or running, rowing, or, 
in fact, any exhausting exercise. It is impor- 
tant to recognize that, although such exercise 
be taken in the open air, it is conducive to the 
development of consumption if it entail ex- 
haustion or fatigue. Still more is this the 
case if the exertion be undertaken in vitiated 
atmospheres, and the debilitating effects of 
impure air be added to that of strain. Many 
consumptives bring on their diseases by per- 
sistent neglect of rest, by w r orking too hard 
during the day perhaps and taking it out of 
themselves with pleasure in the evenings." 

78 



SEED AND SOIL 

A case illustrative of the above recently oc- 
curred in the author's experience: A young 
man living under exceptionally good hygienic 
conditions developed tuberculosis; in seeking 
the predisposing cause, it was found that be- 
sides doing an exacting day's work, he was 
obliged to make a considerable journey twice 
daily to and from his work, and thus, as he 
confessed, he was in a constant state of over- 
fatigue. 

Worry 

Worry is still another predisposing cause, 
for it depresses the nervous system, which 
interferes with the healthy normal functions 
of the body, and this reduces its power of 
resistance. In the treatment of the disease 
in sanatoriums, it has been found that patients 
fail to improve or retrograde if their minds 
are not at ease, and they worry over the family 
left at home or some other real or imaginary 
trouble. Contentment of mind is an essential 
condition for the maintenance of a good bodily 
condition. The man who worries or whose 
mind is overburdened with care is preparing 
a fruitful soil for the tubercle bacillus, like 
Cassius of the " lean and hungry look," who 
79 



TUBERCULOSIS 

"thinks too much," who "loves no plays/' 
and " hears no music," who " seldom smiles," 
and " scorns the spirit that could be moved to 
smile at anything." He is in a receptive 
condition either for an invading infectious 
germ, or a great tragedy, as in the case 
of the ill-starred Cassius. Peace of mind 
and contentment are as essential for the 
body as the spirit. " A merry heart doeth 
good like a medicine : but a broken spirit dri- 
eth the bones." 

Monotony of Occupation 

Monotony of life exercises a depressing in- 
fluence upon the body, and therefore acts as 
a predisposing cause to tuberculosis. In the 
industrialism of the present day when the 
workman or operative performs a single act 
over and over again in the manufacture of 
any article, the monotony of it becomes de- 
pressing. So with the housewife whose daily 
round of household duties is ever the same 
and never done. To obviate the evil and de- 
pressing influence of such monotonous occu- 
pations, diversion and amusement must be 
afforded, so that one may forget for an hour 
that he is a cog in the wheel of the great 
80 



SEED AND SOIL 

machine, and thus refreshed in mind he can 
return to his labor with renewed vigor to 
endure the monotonous round of his existence. 
To provide clean amusement for the people 
is an hygienic measure of the first importance. 
To have a healthy body we must have a 
healthy mind. 

Tuberculosis has been well called the 
" disease of the masses," for it thrives upon 
human misery and poverty. The tenement 
house with all its evils of overcrowding; 
want; excessive hours of labor; absence of 
fresh air and sunlight; alcohol, often, alas! 
the only solace and diversion of the poor man, 
vie with each other in preparing a fertile soil 
for the deadly tubercle bacillus. Any and 
every measure which makes for the improved 
living conditions of the masses is a redoubt- 
able foe to all these many predisposing influ- 
ences. We must render the soil sterile as 
well as control the seed. 



81 




VI THE RECOGNITION AND SYMP- 
TOMS OF TUBERCULOSIS 

INCE the discovery of the cause 
of tuberculosis, the study of the 
disease has been renewed with 
great vigor and interest. Par- 
ticularly is this the case in the 
endeavor to discover it at an early stage, when 
it is just beginning, and when it can be treated 
with the greatest probability of success. In 
earlier times tuberculosis was not generally 
detected until it had made considerable prog- 
ress and was in what we should now call a 
more or less advanced stage, and when it had 
seriously affected the general health. By a 
careful study of the symptoms and by im- 
proved methods and greater skill in physical 
examination, the physician can generally rec- 
ognize the disease at an early period. Unfor- 
tunately, however, many persons suffering 
from it are all unconscious of the fact and do 
not seek the physician until the disease is 
advanced and the most favorable time for 
82 



SYMPTOMS 

treatment has passed. Hence the great im- 
portance of seeking an examination if some or 
any of the suspicious symptoms are present 
which one can easily detect, and which sug- 
gest the possibility of tuberculosis. 

Early Symptoms 

Such symptoms are a slight hacking cough, 
perhaps only occurring in the morning, and 
which persists, accompanied with a slight 
amount of expectoration, — one often deceives 
himself by regarding such a cough as only a 
slight " cold," — a loss of weight and strength, 
and a general feeling of debility so that one 
does not feel " up " to his work ; a loss or 
impairment of the appetite ; slight fever in the 
afternoon, perhaps preceded by chilly sensa- 
tions; breathlessness on exertion; and some- 
times " night sweats." In the past many cases 
of consumption were mistaken for malaria, 
bronchitis, the " grippe," or only dyspepsia, 
and so went on in a false security until finally 
the sad awakening came and the disease was 
found to be advanced. Bleeding from the 
lungs, which is called " haemoptysis," may be 
the first symptom which calls attention to 
tuberculosis; and it is sometimes fortunate 

83 



TUBERCULOSIS 

that this symptom which, in the early stage, 
is not so serious as alarming, occurs in the 
beginning of the disease, for the patient in 
his alarm hurries to the physician, and thus 
the disease is discovered at an early period 
and timely treatment begun. 

It is interesting to know how the physician 
goes to work to make what is called a " physi- 
cal examination " of the lungs. He first be- 
gins by " inspection," looking at the bare chest 
of the patient and observing its shape, irregu- 
larities, and its movements in breathing. 
Sometimes one side of the chest will have 
less movement in respiration than the other, 
which suggests that on the side of less move- 
ment there may be some tuberculous deposits 
which restrict the respiratory movement. 
Again, the physician may notice that there is 
a slight depression at the top or apex of one 
side of the chest, which again suggests tuber- 
culosis. After obtaining all the information 
he can by inspection, the physician next pro- 
ceeds to employ the two most valuable meth- 
ods of physical examination, called " percus- 
sion " and " ausculation," which depend upon 
the resonant qualitv of the lungs, and the 
84 



SYMPTOMS 

sounds which are produced in them by the act 
of breathing, or talking. 

How the Lungs Are Tested 

The method of " percussion " or tapping 
with the ringer or an instrument, like a little 
hammer, upon the chest wall, sometimes called 
" sounding " the chest, was discovered long 
ago by a Viennese physician named Auen- 
brugger, who published his discovery in 1 76 1 
in a little book written in Latin, entitled the 
" New Invention." In the preface he says : " I 
present to you, charitable reader, a new sign 
which I have discovered for detecting diseases 
of the chest. This consists in the percussion 
of the human thorax, from the varying reso- 
nance of the sounds of which an opinion can 
be formed of the internal condition of this 
cavity." For forty-seven years this inestima- 
ble discovery of Auenbrugger seems to have 
been lost sight of, when Corvisart, a French- 
man, who was the physician of Napoleon, re- 
discovered it and translated Auenbrugger's 
little book into French in 1808. From that 
time to the present percussion has been in 
constant use by physicians, and will always 
85 



TUBERCULOSIS 

remain a method of the greatest value in 
examining the chest. 

"Auscultation," "that wonderful art of 
discovery of disease," says Dr. Oliver Wendell 
Holmes, " which, as it were, puts a window 
in the breast through which the vital organs 
can be seen to all intents and purposes," was 
discovered by a French physician, Laennec, 
who published a treatise upon it in 1819. 
" Before Laennec," says some one, " clinical 
observation, though never blind, had been al- 
ways deaf." By auscultation we are enabled 
to listen to the sounds of breathing and the 
voice sounds as they are re-echoed in the 
chest, and also to detect other abnormal sounds 
which disease causes in the lungs. When 
one is familiar with the normal sounds of 
breathing and of the voice, he is enabled to 
determine when these sounds are changed by 
disease or when other sounds not present in 
health occur. Thus, the physician can by ex- 
perience tell the peculiar sounds, and modifica- 
tions of the normal sounds, which are pro- 
duced when there are tuberculous masses in 
the lungs, if these masses are large enough to 
affect the normal sounds. 

In practicing auscultation an instrument 
86 



■ .,...••'■•.,..■■■ 




THEOPHILE LAENNEC, 
Discoverer of Auscultation. 



SYMPTOMS 

called the stethoscope is employed, one end 
of which is applied to the patient's chest and 
the other to the physician's ears. Laennec, 
who made the first stethoscope, which was 
simply a hollow wooden cylinder a foot long, 
thus happened upon this invaluable discovery : 
He was one day consulted by a stout young 
woman with symptoms of heart disease. On 
account of her stoutness and her age and sex, 
he was prohibited, he says, from applying his 
ear directly to her chest. Taking up a quire 
of paper from his desk, he made a tight roll 
and applied one end of it to the chest of the 
young girl and the other to his ear. With 
delight he found that in this way he per- 
ceived much more plainly the beating of the 
heart. 

" What millions of physicians," says a 
writer upon Laennec, " must have attended 
millions upon millions of chest disease between 
Hippocrates and Laennec, and yet Laennec 
was the man and mind wanted to make, or 
rather to complete, a discovery that had been 
lying ready for birth some thousands of years. 
It waited for the fat young lady with heart 
disease whose chest could not be touched by 
ears polite, for the quire of paper that ad- 

87 



TUBERCULOSIS 

mitted of being rolled into a tube for listening 
through, and for this man Laennec to do 
the part of thoracic eavesdropper." 

It seems the irony of fate that Laennec, 
who devoted his life and genius to the study 
and detection of tuberculosis, should have 
himself died of this disease at the age of forty- 
five; but his work lives after him, and every 
time the physician uses the invaluable method 
of auscultation and applies his stethoscope to 
the patient's chest he thinks with gratitude of 
this renowned Frenchman who, for the good 
of humanity, placed this means of examination 
in his hands. 

It requires a keen ear and one accustomed 
to detect slight variations in the pitch and tone 
of sounds to be successful in percussion and 
auscultation, and it is not surprising to learn 
that both Auenbrugger and Laennec were 
lovers of music. Indeed, Laennec was a mu- 
sician and played upon the flute, while Auen- 
brugger attuned his ear by listening to good 
music. Of all the methods of physical exami- 
nation of one suspected of having tuberculosis, 
percussion and auscultation are the most valu- 
able, for they " enable us in many cases," as 
Dr. Holmes so wisely says, " to distinguish 
88 



SYMPTOMS 

phthisis (tuberculosis) before its existence is 
shown by the general symptoms, at a period 
when we can say, do this and you may live, 
do that and you must die." Not infrequently, 
however, we are unable to determine the ex- 
istence of tuberculosis by the most painstaking 
physical examination; but our resources are 
not yet at an end. We have other valuable 
aids. 

Examination of the Sputum 

The first is one which is always employed 
by physicians when possible, that is, when any 
expectoration can be obtained, which is not 
always the case in the very early stage of the 
disease: it is the examination of the sputum, 
to see if there are the germs of tuberculosis, 
the tubercle bacilli, in it. By means of cer- 
tain staining fluids we can color the tubercle 
bacilli, which will retain the stain when it is 
washed away from the other portion of the 
sputum. When the sputum is so prepared and 
placed under the microscope, the bacilli, if 
they are present, are seen as tiny red rods. 
So characteristic are they that when once ac- 
customed to their appearance, they cannot be 
mistaken. 

8 9 



TUBERCULOSIS 

When the bacilli, or tuberculosis germs, are 
found in the sputum, it is a sure proof that tu- 
berculosis exists; but not infrequently, in the 
very beginning of the disease, and also when it 
is more advanced in certain cases, the germs 
are, for one reason or another, not found, so 
that we are not justified in saying that there is 
no tuberculosis when this is the case if there 
are other symptoms and signs of the disease. 
We must then turn to other tests. So impor- 
tant, however, is the examination of the spu- 
tum, which, when successful, or " positive," 
as we say, is an absolute proof of tuberculosis, 
that state and city boards of health now main- 
tain free laboratories to which physicians can 
send the sputum of a suspected case of tuber- 
culosis and have it examined by an expert. 
All medical students also are now taught to 
make the sputum examination for tuberculosis 
in the interest of their future patients. 

The Tuberculin Test 

Another modern aid is the " tuberculin test." 
We have already spoken of tuberculin in the 
previous chapter, and it is this same tuberculin 
which is employed in making the tuberculin 
test. A very minute quantity is either in- 
90 



SYMPTOMS 

jected into the suspected individual, or he is 
vaccinated with it much as we vaccinate for 
small-pox, or a drop of a very dilute solution 
is put in the eye. If tuberculosis exists any- 
where in the body, we generally obtain a " re- 
action," as it is called, in the case of an injec- 
tion ; or, if used by vaccination or in the eye, 
certain characteristic appearances are ob- 
served. This test is not always sure, but it 
is a very great aid in detecting early tubercu- 
losis. Long and large experience with the use 
of tuberculin in this way has proved that it is 
not injurious if carefully applied by the physi- 
cian. 

The tuberculin test is also used with great 
success in the testing of cattle, especially cows, 
and is now generally employed with dairy 
herds in order to safeguard the milk. 

So the world is not only indebted to Pro- 
fessor Koch for the discovery of the cause of 
tuberculosis, but for this very valuable aid 
in detecting it at an early period. 

The X-Ray 

Still another aid in the detection of tubercu- 
losis is the X-Ray, now so generally known 
and used, particularly by surgeons. By means 
91 



TUBERCULOSIS 

of this wonderfully penetrating light we can 
actually look through the body, and it becomes 
almost as transparent as was Marley's ghost 
when old Scrooge, in Dickens' " Christmas 
Carol/' looked through it as it stood in his 
bed chamber and saw the two buttons on its 
coat behind. The lungs in health are quite 
translucent to the X-Ray light, but when 
there is tuberculosis in them, a dark shadow 
appears, the tuberculosis deposit prevents the 
light from penetrating them. So by the 
X-Ray picture we can often detect evidences 
of tuberculosis which cannot be discovered 
by the other methods of examination. 

By having at our command all these vari- 
ous methods of examination and by carefully 
taking into account all the symptoms, we are 
enabled almost always to recognize pulmonary 
tuberculosis in its commencement or at least 
strongly suspect it and so begin the treatment 
when there is every hope of cure. With chil- 
dren the detection of tuberculosis is generally 
more difficult than with adults, for among other 
difficulties, they do not expectorate and we 
cannot have the help which the sputum exam- 
ination affords. With all the methods of 
examination, however, and the skill of the phy- 

9 2 



SYMPTOMS 

sician, the disease is more frequently discov- 
ered in children than formerly, and it has been 
shown that it is far more prevalent in them 
than was previously supposed. 

Closed Tuberculosis 

It has been said above that sometimes in 
the beginning of tuberculosis the germs are 
not found in the sputum, and it is also true 
that in some of these early cases there is no 
sputum. We call such cases " closed " tuber- 
culosis. If, therefore, we can detect, treat 
and cure these " closed " cases before they 
become "open," or have sputum containing 
germs, we protect the community by just so 
much from the dangers of contracting the 
disease. For such cases, if they were allowed 
to go on and become " open," or communi- 
cable, and if they did not properly destroy 
their sputum, would give the disease, it is esti- 
mated, to three times as many more on an 
average. 

The Only Safe Way 

In the very beginning of tuberculosis, there 
are frequently few, if any, symptoms, and the 
individual does not feel really ill. How, then, 
93 



TUBERCULOSIS 

is he to know that he is in any danger, and 
seek an examination of his lungs? The only 
safe way is occasionally to have one's lungs 
examined, particularly if there has been any 
exposure to the disease, as in a family where 
some member is suffering from it. School 
children and students should be periodically 
examined, particularly on graduation from 
school or college, for if any evidence of tuber- 
culosis was shown, advice with regard to the 
choice of an occupation would be of inestima- 
ble value. How many young lives just be- 
ginning their career might have been saved 
from an untimely ending through tuberculosis 
if this plan had been followed! 

In the same way, if all operatives in work- 
shops and factories, employees in department 
stores and clerks could receive a periodic 
examination of their lungs, many lives would 
be saved, and those associated with them 
would be protected from the possibilities of 
contracting the disease. When we remember 
that from one-fourth to one-third of all deaths 
between the ages of fifteen and forty-five or 
fifty years are caused by tuberculosis, there 
is the very greatest reason why all persons 
during this age should from time to time have 
94 



SYMPTOMS 

their lungs examined. If such a mortality 
as now occurs from tuberculosis was known 
to exist from a single disease among a choice 
breed of cattle, horses, sheep, or what not, how 
quickly would the owners use every protective 
means to safeguard their stock. " How much 
then is a man better than a sheep " ! 

There are many difficulties in discovering 
tuberculosis at an early period among wage- 
earners and the poor. In the first place, the 
workingman cannot afford to give up his 
work until actually disabled ; and, again, he is 
often ignorant of the meaning of his symp- 
toms, or, if he does suspect that he has tuber- 
culosis, he fears that its discovery may lead 
to the loss of his occupation and hence the 
livelihood of himself and family. Finally, if 
he has to pay for his examination, he may not 
have the means to do this. 

To obviate this, there are now established 
all over the civilized world — and their number 
is being daily increased — free tuberculosis dis- 
pensaries where a reliable examination of the 
lungs can be obtained without expense to the 
poor man. These beneficent institutions in 
connection with the popular dissemination of 
the simple truths concerning tuberculosis are 
95 



TUBERCULOSIS 

of the highest value in securing to the work- 
ingman an early examination of his lungs. 

In connection with such dispensaries there 
are trained nurses, social workers, or visitors 
who visit every home where a case of tuber- 
culosis is found to exist, and who, besides ad- 
vising the consumptive member how to prop- 
erly conduct his life so as to avail himself of 
all his chances of recovery, if he is treated at 
home, urges all the other members of the 
household to go to the dispensary for an exam- 
ination. In this way, many early cases of tu- 
berculosis are discovered and thus we are 
enabled, as Dr. Pryor has so well and epigram- 
matically said, " to care for the consumptive in 
the right place, in the right way, and at the 
right time until he is cured; instead of in the 
wrong place, in the wrong way, at the wrong 
time until he is dead." 

Points to Remember 

Consumption is curable in the larger num- 
ber of cases if treated at an early stage. 
Hence, an early detection of the disease is of 
the very greatest importance ; and among the 
earlier symptoms which anyone can observe 

96 



SYMPTOMS 

(and, finding 1 which, he should at once seek 
the physician) are: 

(a) A slight cough, or a cold, lasting a 
month or more. 

(b) Loss of weight. 

(c) Slight fever in the afternoon. 

(d) Loss of strength, or a tired feeling. 

(e) Shortness of breath on exertion. 

(f) Loss or impairment of appetite. 

(g) Bleeding from the lungs. 

A wise English physician gives this advice 
to doctors : " Always say three things to a 
patient whom you suspect to be phthisical 
(tuberculosis) : 

"(i) 'Get yourself weighed — by the same 
machine each time — to see if you are losing 
weight.' 

(2) * Use a thermometer two or three 
times each evening, to see if there is any 
fever/ 

(3) ' Save your sputa to be tested (for ba- 
cilli).'" 



92 




VII. THE CURABILITY OF TUBER- 
CULOSIS AND ITS TREATMENT 

GREAT change has taken place 
in recent times in the opinion 
both of physicians and the public 
regarding the curability of tu- 
berculosis. As was stated in the 
conclusion of the last chapter, tuberculosis is 
now regarded as one of the most curable of 
chronic diseases, provided the treatment is be- 
gun early, before the disease has made any 
serious inroads upon the general health and 
constitution. Experience, that infallible 
teacher, extending over many years, has 
abundantly verified this statement. 

Formerly Regarded as Hopeless 

Formerly, however, tuberculosis was con- 
sidered well-nigh hopeless by the majority of 
physicians, principally due to the fact that 
they did not know how to discover it, as a 
rule, until it had reached an advanced condi- 
tion. 

98 



CURABILITY .AND TREATMENT 

Louis, one of the most celebrated French 
physicians, declared more than eighty years 
ago that tuberculosis was a well-nigh hopeless 
disease, and almost invariably terminated 
fatally; and Dr. Stoll, an old English physi- 
cian, speaks of an eminent divine who declared 
that it was blasphemy to assert that the dis- 
ease (tuberculosis) was curable, " for God 
himself had made it incurable." Dr. James 
Jackson, a distinguished physician in Boston 
in his day, wrote in 1855 that consumption 
was almost uniformly fatal; and Dr. Wilson 
Fox of London, as late as 1887, declared that 
complete cures of consumption was a rare 
event. 

From the time of Hippocrates down the 
ages, however, there was now and then a keen 
physician who declared his belief in the cura- 
bility of tuberculosis. Hippocrates himself 
believed this. Laennec, of whom we have al- 
ready heard, declared that the cure of con- 
sumption when the lungs are not completely 
diseased, ought not to be looked upon as at 
all impossible ; and after reviewing the various 
cures suggested at that time, such as bleeding, 
blisters, purgatives, the inhalation of different 
gases, the air of cow houses, acorns roasted 
99 



TUBERCULOSIS 

or raw, mushrooms, crabs, oysters, frogs, 
vipers, emetics, etc., finally concludes with the 
following wise remark, "that although the 
cure of consumption may be possible for na- 
ture, it is not so for medicine." Would that 
the last part of this sentence was always kept 
in mind at the present day, for even now many 
a poor consumptive believes that medicine or 
some of the innumerable quack remedies can 
cure him. 

Useless Remedies 

Numberless remedies have at one time or 
another been extolled and applied, often to the 
injury, if not worse, of the unfortunate con- 
sumptive. A hundred years ago, emetics and 
cathartics were a popular form of treatment 
of tuberculosis, as of many other diseases. 

Dr. Stoll of Hartford, Conn., who has writ- 
ten a very interesting account of the early 
treatment of consumption, quotes a Dr. Parr 
as saying, " Could phthisis (consumption) 
ever be cured it would be by joint action of 
emetics and blisters " ; and there is a record 
of a woman, aged forty years, who took 600 
emetics in ten years. The result of this heroic 
treatment is not given, but it is not difficult to 
guess. Bleeding was another popular method 
100 



CURABILITY AND TREATMENT 

of treatment, and Dr. Stoll refers to advice 
given to a consumptive to " lose six ounces of 
blood each day for a fortnight, if he lived so 
long!" Residence in a cow house was an- 
other treatment, founded on the theory that 
the " vapors " and heat from the cows were 
somehow beneficial. This form of treatment, 
however, did not seem to be very kindly re- 
ceived, and a certain physician who was ac- 
customed to advise it, remarks : " Not infre- 
quently did I forfeit the good opinion of my 
patients." Almost everybody believed night 
air injurious as well as cold air, and con- 
sumptives were advised to shut themselves up 
in the house during the coldest months of the 
winter. The two striking features in the 
treatment of the disease during the last cen- 
tury were the removal of the patient to a 
milder climate, no matter what the stage of 
the disease, and the use of cod liver oil. 
Multitudes were sent away to die far from 
home, and the nauseous oil destroyed the di- 
gestion of not a few. 

The True Theory of Treatment 

Here and there, however, as has been said, 
there were a few wise physicians who believed 

IOI 



TUBERCULOSIS 

that consumption was at least sometimes cura- 
ble and were sagacious enough to recognize 
that the essential treatment was not by drugs 
and depressing measures, but by supporting 
the patient and increasing his resisting powers. 
Thus, in 1804, there was a Dr. Stewart of 
England, who was both a clergyman and 
physician, whose treatment " was founded," 
as one of his patients expressed it, "upon 
every principle of common sense," and who 
"supported the constitution and enabled it to 
throw off the disease by its own rallying 
powers." In 1840 George Bodington, a coun- 
try doctor in England, presented a method of 
treatment to his medical brethren which he 
called, " The cure of pulmonary consumption 
on principles natural, rational and successful," 
and established a sanatorium in which he car- 
ried out his treatment, which was essentially 
the " open-air method " of to-day. The pub- 
lic, however, was not ready for such a radical 
innovation upon the old-established drugging 
method, and bitterly opposed him, as did his 
own professional colleagues. His patients 
forsook him and he was finally obliged to turn 
his institution into an insane asylum, and he, 
indeed, was regarded as a lunatic. In 1855 
102 



CURABILITY AND TREATMENT 

Dr. Henry McCormac, of Belfast, Ireland, 
wrote a book in which he advocated a similar 
method of treatment to that of Bodington's; 
but he, also, met the fate of his predecessor, 
and was bitterly opposed and even persecuted. 
Such is so often the experience of those who 
present some new discovery or device which is 
contrary to the accepted opinions of the times ; 
they find but few daring spirits who are will- 
ing to investigate with open mind the new 
ideas, and who are ready to accept them if 
they offer something better than what exists. 
Such has often been the case within the medi- 
cal profession itself. 

Finally Brehmer, a German pioneer in the 
modern treatment of tuberculosis, established 
in Goerbersdorf, Germany, the first sanato- 
rium, fifty or more years ago, conducted upon 
the modern principles of the out-door treat- 
ment, and which is still in operation. 

Gradually at first, and later more rapidly, 
similar sanatoria have sprung up in almost 
every civilized country, until now the new idea 
of treatment has become thoroughly estab- 
lished. 

After the cause of tuberculosis had been 
proved to be a specific germ — the tubercle ba- 
103 



TUBERCULOSIS 

cillus— there was a new search begun to find 
a specific remedy which would destroy this 
germ in the lungs and so stop the disease. It 
seems to be an instinct in human nature to be 
ever seeking a specific remedy, an easy cure, 
for the diseases of mankind; to swallow a 
drug seems to so many persons a much more 
direct and easy method of cure than the slower 
and more certain process of following Na- 
ture's laws and correcting errors in one's 
mode of life. 

At first some substance was sought for 
which could be injected into the lungs and kill 
the bacillus, but nothing has ever been dis- 
covered which will do this without killing the 
patient. Again, various antiseptics have been 
tried, applied in one way or another, by inhala- 
tions, vapors, or taken internally, for the same 
purpose of destroying the bacillus, or prevent- 
ing its activity, but they likewise have all 
failed. Still the search goes on and hardly 
a week passes that some new specific is not 
extolled as a " sure cure " for consumption, 
but, like Job's friends, they are all " miserable 
comforters " ; they have their little day, fail, 
and pass into oblivion. 

The only treatment which has stood the 
104 



CURABILITY AND TREATMENT 

test of time and the one universally employed 
at the present day is the so-called " open-air 
treatment." When it is recalled that in for- 
mer times the unfortunate consumptive was 
confined in a closed room, so great was the 
fear of taking more cold (for, because the 
cough was the most prominent symptom, it 
was really regarded as the disease itself), it 
will be realized how radical a change from 
this old method is the new one of the out-door 
life. 

The Out-Door Treatment 

The principle of the " open-air treatment " 
is simple and consists in re-establishing the 
power of resistance of the consumptive by in- 
creasing his vital powers, — in brief, to pro- 
duce and maintain a high degree of bodily 
health. The whole treatment is, in a sense, 
an indirect one, a treatment of the individual 
rather than of the disease. As in the case of 
so many other diseases for which we have no 
specific remedy, it is simply putting the con- 
sumptive in the most favorable condition to 
fight his own disease; it is developing to the 
highest degree his " natural immunity," of 
which we have before spoken. This seems 
105 



TUBERCULOSIS 

very plain and easy in the statement, but it 
really requires much patience and power of 
will to adhere rigorously to a strict daily 
routine of living, extending over a consider- 
able period of time, even for years, it may be, 
in some cases. 

There are four essential requisites in this 
treatment : 

(i) Competent and continued medical 
supervision. The physician must plan, direct 
and supervise the daily life of the consump- 
tive. No one should undertake the treatment 
without being in touch with a competent 
physician. 

(2) Continuous out-door life. The con- 
stant and continuous exposure of the patient 
to pure out-door air night and day. During 
the day the patient remains out-of-doors, 
either at rest in a reclining chair, like a ship's 
chair, or, later in the course of the treatment, 
taking a limited amount of exercise on the 
advice of the physician only. If there is 
fever, even a little rise of temperature, abso- 
lute rest is required. At night, one either 
sleeps directly out of doors, as is so fre- 
quently done at the present time — and even 
the well are adopting this wholesome habit— 
106 



CURABILITY AND TREATMENT 

or in a large room with wide open windows 
whatever the weather outside may be. There 
are also devices, such as window tents, or es- 
pecially constructed beds, whereby one's head 
can be out-of-doors while his body is in the 
room. It used to be thought that night-air 
was injurious, but we know now that it is as 
good as day-air, and sometimes better, as in 
cities, when there is less dust in the air at 
night on account of the decreased traffic. 

(3) Good Food. An abundance of good 
nourishing food, properly arranged as to 
quantity, quality, and the digestive powers of 
the individual, and, which is most essential, 
properly cooked. 

(4) Tranquillity and hopefulness of mind, 
for the mental condition has much to do with 
the success of the treatment. An unhappy, 
discontented patient is less likely to improve 
in this or any other chronic disease, as has 
been referred to in the previous chapter. The 
writer once had a patient who became a Chris- 
tian Scientist, and it produced such a tranquil, 
hopeful state of mind in him that, whatever 
his personal opinion with regard to this 
pseudo-science may be, it apparently in this 
case greatly aided in the successful issue. 

107 



TUBERCULOSIS 

One might add a fifth essential, so univer- 
sally is it employed in the treatment, namely, 
the cold sponge or shower bath in the morn- 
ing. Of course this is only to be taken under 
the advice of the physician, for there are cer- 
tain conditions or symptoms which would 
render it injurious. 

The whole treatment should be most care- 
fully arranged and constantly supervised by 
the physician, who must in the most pains- 
taking manner personally attend to every de- 
tail, — he must provide for every hour in the 
day^ as will be further considered in a sub- 
sequent chapter. 

The patient must be truthfully told of his 
condition and its dangers, as well as the hope- 
ful outlook from treatment if he implicitly 
obeys his physician. It is a mistaken kind- 
ness to keep him in ignorance of his true con- 
dition ; he is sure to discover it later, and then 
he will lose confidence in his physician. 
Moreover, if he knows his condition, he will 
realize more fully the importance of adhering 
rigorously to the treatment. 

From In-Door to Out-Door Life 

Consumption, as has been already said, is 
108 



CURABILITY AND TREATMENT 

a disease of in-doors, a " house disease," and 
the in-door life must be changed to an out- 
door one. This is a very radical change, and 
it requires a little time to become accustomed 
to it. 

One may be apprehensive of taking cold, 
or fear that he has not sufficient strength 
to endure the exposure, especially in cold 
weather. When once, however, the out-door 
habit is acquired, enthusiasm takes the place 
of fear ; the sense of well-being caused by the 
stimulating effect of the constant exposure to 
pure air is so keen, and the evidence of the 
beneficial effects in the improvement of all the 
symptoms, particularly the appetite, is so ap- 
parent, that one soon acquires a zest for this 
new mode of existence and wonders how he 
could have ever been content with his in-door 
life. " In spite of rain, fog or snow," says 
Dettweiller, a pioneer in this form of treat- 
ment, " in spite of a temperature below zero ; 
very often without sun, the patient spends 
from seven to ten hours out-of-doors and 
sometimes even eleven hours. . . ." After 
a while one acquires such a hunger for fresh 
out-door air that he feels he cannot live with- 
out it. 

109 



TUBERCULOSIS 

In sleeping out-of-doors, whether it be in a 
sleeping porch, on the piazza, or by use of the 
out-door bed or window tent, one can be made 
really comfortable by warm garments and bed 
clothes, a woolen hood for the head, and a 
soapstone or hot water bottle for the feet; 
so that he can sleep peacefully even in the 
winter months of northern latitudes. During 
the winter of 1903-1904, fifty per cent, of the 
patients at the Adirondack Cottage Sanato- 
rium slept out-of-doors, not only without in- 
jury, but with apparent benefit, though it was 
one of the coldest winters known there for 
many years. One surprising fact observed 
with those taking the open-air treatment is 
the inf requency of colds, — no one has any fear 
of a draught, that bugbear of the in-door 
dweller. 

Rest in the Cure 

Experience has shown that while taking the 
" cure," as it is called, a great deal of rest is 
necessary, particularly in the beginning. This 
is in accordance with the general law of Na- 
ture, that an injured part or diseased organ 
requires rest for recovery. 

After the disease is well on the road to 
recovery and the temperature is normal, then 
carefully graded exercise can be begun and 
HO 



CURABILITY AND TREATMENT 

gradually increased if no injurious effects fol: 
low. It has been found that exercise under 
these conditions increases the " natural im- 
munity " of the body. Formerly the very 
hazardous advice used to be given to the con- 
sumptive to get out-of-doors and exercise: 
go West and ride horseback on the plains. 
Sometimes this advice would be followed by 
success, but more times the poor patient ruined 
his chances of cure by so doing. Exercise 
must be as carefully administered and regu^ 
lated as any other part of the treatment. At 
the Frimley Sanatorium in England a very 
carefully arranged series of graduated exer- 
cises of various kinds and degrees is employed 
for suitable patients, constantly supervised by 
the physician; and the Frimley example has 
been followed with equal success in other sana- 
toria. The open-air treatment can be car- 
ried out either in a sanatorium, at one's home, 
or in a health resort which is considered to 
possess certain climatic excellencies. 

The Sanatorium and Its Advantages 

Probably the " cure " can be most effect- 
ively and successfully conducted for the ma- 
jority of consumptives in the modern sana- 
torium, although it must be borne in mind that 
I it can be accomplished anywhere if the system 
III 



TUBERCULOSIS 

is rigidly adhered to and tolerably pure air is 
attainable. In the first place, the sanatorium 
is built and equipped for the express purpose 
to which it is devoted, and its physicians are 
selected for their skill, experience and per- 
sonal fitness for this especial work. Being 
constantly upon the ground, they exercise con- 
tinuous supervision over the patients and en- 
courage them in the prosecution of the cure. 
For the poor the State Sanatorium offers bet- 
ter opportunities than could be obtained at 
home ; while for the well-to-do the " paying 
sanatorium," so-called, offers advantages 
which only with difficulty and greater expense 
could be secured at home. Indeed, in some 
homes, the patient could never be controlled 
sufficiently to successfully make the " cure." 
Again, by going to the sanatorium, all possi- 
bility of infecting other members of the house- 
hold is avoided, for with the best intentions 
and the exercise of great precaution, infec- 
tion may occur through carelessness in dispos- 
ing of the sputum. This danger is greater 
obviously in the crowded homes of the poor. 
The sanatorium is, again, an excellent train- 
ing school in the ways of the open-air treat- 
ment. Even if the consumptive is subse- 
quently treated at home, a few weeks spent in 

112 



CURABILITY AND TREATMENT 

a well-conducted sanatorium is the quickest 
and most effective way to learn the open-air 
method of treatment ; for the patient sees, day 
after day, how it is done, and he quickly falls 
into the routine and follows " the lead." The 
sanatorium patient is made to feel that he is 
taking advantage of every favorable condition 
in his case, and all he has to do or think of is 
to follow out, from day to day and hour to 
hour, the plan of life arranged for him, — he 
is freed from all responsiblity in the manage- 
ment of his case, which is a favorable attitude 
of mind for recovery. 

As the cured patients go forth from the 
sanatorium, they become apostles of the fresh 
air life and wholesome living in the com- 
munities in which they reside. A graduate 
of one of the State Sanatoria changed his 
previous in-door occupation to that of a milk- 
man for the sake of the open-air life, and it 
was soon observed that the windows of the 
houses on his milk route were more widely 
and constantly open than in other portions of 
the town: he had been preaching the gospel 
of fresh air. 

Alleged Objections to the Sanatorium 
A frequent objection urged against the san- 
ii3 



TUBERCULOSIS 

atorium is that the influence from the aggre- 
gation of so many consumptives is depressing. 
That fact, however, is quite the reverse, as is 
attested both by those in charge of them as well 
as by the inmates. One encourages another, 
and the improvement observed in one patient 
inspires another, while the physician in charge, 
if he possesses the requisite qualifications, en- 
courages and inspires all. Furthermore, the 
patient's time is so fully occupied in making 
the " cure " that he has none for depressing 
introspection. In a private letter written to 
the director of a sanatorium, a former inmate 
thus gives his impressions : " A happier set 
of invalids I never saw. At my table none 
looked ill, and were as intelligent and refined 
and jolly a crowd as I have seen all summer. 
I have visited in my time many hospitals, 
asylums and homes, but none like this." 

Another objection raised is the danger of 
reinfection, — of getting another dose of 
germs, where there are so many consump- 
tives in such close intimacy. There is no 
proof, however, that this happens. Every- 
thing in and about the sanatorium is kept 
scrupulously clean, and the utmost watchful- 
ness is observed in the care of the sputum. 
114 



CURABILITY AND TREATMENT 

Any inmate found to be careless in this re^ 
spect is instantly discharged. A director of 
a sanatorium once told the writer that a sue- 
cessful plan he pursued to prevent any care- 
lessness in spitting- among the inmates was tc 
tell each one that he might receive a new infec- 
tion and thus jeopardize his chance of recov- 
ery if anyone else should expectorate upon the 
floor or ground or anywhere else where it 
could become dry; therefore he must sharply 
watch all the others for his own protection. 
Thus everybody was watching everybody else : 
the law of self-preservation worked most ef- 
fectually. 

Examination of the dust in various sana- 
toria and consumptive hospitals has rarely re- 
vealed the presence of the tubercle bacilli, and 
then only when some patient was found to 
have been careless in the disposal of his spu- 
tum. As has elsewhere been mentioned, the 
sanitary conditions in communities where 
sanatoria exist have improved, the death rate 
has fallen, and tuberculosis among the in- 
habitants has diminished. 

No Medicine Used in the Sanatorium 

Practically no medicine is employed in the 
"5 



TUBERCULOSIS 

modern treatment of tuberculosis, except tem- 
porarily in the treatment of some symptoms. 
Even for cough, which is, perhaps, one of the 
most frequent and constant symptoms, medi- 
cines are rarely used, for experience has shown 
that fresh air is the most efficacious of all 
remedies. Furthermore, the patient can be 
trained to suppress all unnecessary coughing 
—that which is accompanied by no expectora- 
tion. Dr. Dettweiller used to tell his pa- 
tients that they could not come to the public 
dining table if they coughed, " for," he said, 
" it is impolite to scratch one's head in public, 
and equally so to scratch one's throat." A 
good method of controlling a useless cough 
is, whenever the inclination to cough is felt, 
to tightly close the mouth and take several full, 
slow breaths through the nose; and repeat 
this until the desire to cough disappears. In 
the majority of cases, however, the cough will 
practically cease under the influences of the 
open-air life. 

Seventy Per Cent. Cured or Arrested in the Early 
Stage 

If consumption is discovered in its incipient 
stage and the open-air treatment immediately 
116 



' CURABILITY AND TREATMENT 

begun, a large experience has proved that 
60 or 70 per cent, or even more can be ap- 
parently cured or " arrested/' As, however, 
the disease becomes more advanced, this per- 
centage rapidly falls to twenty-five or twelve 
per cent., until in far-advanced cases no cure 
or arrest can be expected. How supremely 
important it is, then, to seize the moment when 
the disease is at its beginning to commence 
treatment, knowing that such a large per 
centage recovers at this early stage, for it 
cannot be too often repeated that tuberculo- 
sis is one of the most curable of all chronic 
diseases. It is infinitely true of tuberculosis, 
as of many other things, that "there is a 
tide in the affairs of men, which taken at the 
flood, leads on to fortune." Persistence in 
the treatment, a rigid adherence to the plan 
arranged by the skilful physician without 
changing about from one health resort to an- 
other or one physician to another, as some 
do to their grief, is the condition upon which 
favorable results are to be expected. Eternal 
vigilance is the price of recovery as of liberty. 



"7 




VIII. THE HOME TREATMENT OF 
TUBERCULOSIS 

VEN with the constant increase in 
the number of sanatoria it is ap- 
parent that but a small proportion 
of consumptives can be accommo- 
dated in them, at least in the 
United States, even if they all desired to 
be. The vast majority must be treated 
at home if treated at all. According to Prof. 
Osier probably not more than five per cent, 
can take advantage of the sanatorium or of 
climatic treatment. Fortunately, however, 
the open-air treatment can be successfully 
carried out at home, even in the homes of 
the poor in the city. No consumptive 
need despair if he is unable to seek a new 
climate or enter a sanatorium. The general 
principles of the treatment are, of course, the 
same, but their application must be modified 
to suit the varying conditions of the patient 
and his surroundings. Prof. Osier thus tersely 
outlines the essentials of the home treatment: 
118 



HOME TREATMENT 

" First, the confidence of the patient, since 
confidence breeds hope; secondly, a masterful 
management on the part of the doctor ; thirdly, 
persistence . . . ; fourthly, sunshine by 
day, fresh air night and day ; fifthly, rest while 
there is fever; sixthly, breadstuff s and milk, 
meat and eggs." The "masterful manage- 
ment on the part of the doctor " is of para- 
mount importance, for he must arrange the 
plan to be pursued in all its details. 

It is not by any means only the poor who 
are treated at home. Others in better circum- 
stances may desire, or be compelled from one 
reason or another, to do so. A residence in 
the country or suburbs of the city is, of 
course, to be preferred, for one can obtain 
purer air and more sunshine, and there are 
fewer distractions. If the patient is unaccus- 
tomed to discipline, or a child, the employment 
of a nurse experienced in the treatment, at 
least in the beginning, is of great value. The 
nurse can more quickly educate the patient in 
the details of the cure, and if she is agreeable 
and inspiring, her companionship and en- 
couragement render the routine of the treat- 
ment less irksome. It is frequently possible 
and often wise to send the patient, who is 
119 



TUBERCULOSIS 

subsequently to be treated at home, to the 
sanatorium for a brief period, as has been 
before mentioned, in order that the general 
plan of treatment may be more thoroughly 
and speedily learned. 

The Room of the Consumptive 

The room occupied by the patient should 
have a southern, or southwestern ex- 
posure, not only on account of the sunshine, 
but because it will be cooler in summer 
and warmer in winter. It should be large, 
with abundant window space, and when pos- 
sible have an open fireplace. The furnish- 
ings should be few and plain, without heavy 
hangings or upholstery, which collect and hold 
dust. The floor should be such that it can be 
easily washed; and everything in and about 
the room should admit of easy and thorough 
cleaning. A rug or two may be allowed on 
the floor. The bed, unless one sleeps in the 
open, should be placed in such a position as to 
be continually bathed with fresh air. The bed 
clothing should consist of woolen blankets or 
of eider-down material, the latter having the 
advantage of lightness as well as warmth. 

120 



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THE WALSH WINDOW TENT. 



HOME TREATMENT 

For several hours every morning the bed 
clothes and mattress should be placed in the 
sunlight and well aired. At frequent inter- 
vals the floor, walls and furniture should be 
cleansed with soap and water or wiped with 
cloths wet with a solution of chlorinated lime 
or a weak solution of corrosive sublimate. In 
some cases, where there is a good deal of 
coughing and expectoration an occasional dis- 
infection with formaldehyde gas is advised, 
care being taken that all small articles used 
by the patient, such as books, cards, baskets, 
etc., should receive a thorough fumigation. 
All dusting should be done with a damp cloth. 

The windows are to be constantly open, ex- 
cept when dressing and undressing. When 
in the room and not in bed, the temperature 
should be from 65 ° to 68°. 

A balcony or sleeping porch connected with 
the bedroom so that the bed can be rolled out 
upon it through a low window or door, is a 
very desirable addition. An adjoining bath- 
room, which can be warmed, is also desirable 
for the cold bath in the morning. 

One should sleep alone, and occupy the 
room alone. 

121 



TUBERCULOSIS 

Care of the Sputum 

The sputum (expectoration) should be re- 
ceived in one of the many sputum cups in use, 
or in a cuspidor with water or a disinfectant 
in it, which should always be kept covered and 
the contents burned one or more times a day. 
In coughing a piece of cloth or a Japanese 
napkin should always be held before the 
mouth and subsequently burned. Strict per- 
sonal cleanliness should be observed, the 
mouth and nose washed out several times a 
day, and the hands always washed before eat- 
ing. If any sputum should accidentally get 
upon the floor, furniture or clothes, it should 
immediately be wiped up with soap and hot 
water, or with a five per cent, solution of car- 
bolic acid. The sputum should never be swal- 
lowed, for it may cause further infection. 
One, of course, should never spit anywhere 
except in the proper receptacle. If the hand- 
kerchief is used in coughing or for the spu- 
tum, which is bad practice, it should be washed 
in boiling water before becoming dry. All 
soiled articles of wear should be first boiled 
before being washed. All table utensils 
should be reserved for the patient alone and 
separately washed in boiling water. 

122 



HOME TREATMENT 

How the Day Should Be Spent 

From seven to ten hours should be spent 
out-of-doors daily, winter and summer, and a 
good deal of this time is to be spent at rest, 
especially at the beginning of the treatment. 
If there is fever — a temperature of ioo° or 
over — absolute rest is required. A comfort- 
able reclining chair is employed for the open- 
air rest "cure," for the recumbent position 
has been found to be the most comfortable 
and favorable one. In resting out-of-doors, 
such a place should be selected as will permit 
a good circulation of air, and in the sunshine, 
though it is well to protect the head from the 
direct rays of the sun. Either a piazza, bal- 
cony or some place in the yard about the house 
is suitable; or even on the house top. There 
should be protection from the wind. 

While lying in the reclining chair, one can 
occupy the time in various simple ways : read- 
ing some unexciting literature, like Miss 
Austin's novels, for example, books of travel, 
history, humorous tales, like those of Mark 
Twain, etc. ; or he can engage in some simple 
handiwork, such as basket weaving, wood 
carving, paper cutting, etc., or play an unex- 
citing game with a friend, though much talk- 
123 



TUBERCULOSIS 

ing and visiting is generally a useless expendi- 
ture of strength. If the patient is fortunate 
enough to have a pleasing stretch of land- 
scape before him he will often be content to 
enjoy the view and so let the hours go by, as 
the passenger on the ocean steamship spends 
hours and days sitting idly in his chair simply 
watching the ever-changing scenery of sky 
and sea. A patient who was taking the open- 
air " cure " once remarked to the writer that 
it took him so much time to do nothing that 
he had no time to write a letter. In the homes 
of the city poor, the house top, the back yard, 
a piazza, when there is one, an improvised 
balcony, or even the fire-escape, will serve for. 
the out-door life. 

Day Camps and "Classes" 

The day camp is an admirable and inex- 
pensive method of affording out-door life dur- 
ing the day to those who must remain at home, 
in poor quarters, or crowded portions of the 
city, or while waiting for entrance into a sana- 
torium. For its location an open space is se- 
lected in the environs of the city, where there 
is a free circulation of air, and, if possible, the 
shade of trees. The equipment is simple, — 
one or two rude buildings for the kitchen, 
124 



HOME TREATMENT 

physicians' examining office, etc., and a large 
dining tent or other structure. The consump- 
tive comes to the camp in the morning and 
spends the day in his reclining chair under 
the trees. He is under the supervision of 
the attending physician, and receives several 
nourishing meals during the day. He returns 
to his home at night, to come again the next 
morning, thus spending each day, for weeks 
or months, out-of-doors. Excellent results 
have been obtained from this effective method 
of out-door treatment, and experience has 
shown that it can be continued throughout 
the year. 

The tuberculosis class has become a popu- 
lar and very useful method of treating small 
numbers of poor patients in their homes in a 
large city. It consists of a small group — a 
class — of consumptives, who are under the 
strict supervision of the physician of the class, 
whom they meet regularly once a week, and 
who discusses with them the details of the past 
week and advises them as to their future 
course. Each patient keeps a diary of his 
condition, the food and milk taken, exercise, 
the number of hours spent out-of-doors, his 
temperature and pulse, general condition, etc. 
In addition to the weekly class meetings, a 
125 



TUBERCULOSIS 

nurse visits the patients at their homes and 
sees that they carry out the treatment. Such 
classes are often supported by churches and 
are given the name of the church which has 
charge of them, as the " Emmanuel Church 
Tuberculosis Class," which was the original 
class of this kind, and was the happy concep- 
tion of Dr. Pratt of Boston. The patients are 
aided pecuniarily when necessary by funds 
contributed by the church. Tents, reclining 
chairs, sputum cups and paper handkerchiefs, 
and, in special cases, food are furnished. After 
recovery the patients are often aided in se- 
curing proper employment. 

By means of this admirable method of home 
treatment, many lives have been saved and 
returned to work. Many cities and other 
countries have taken up this system. The edu- 
cational value of the class system is great: 
not only the patients, but their families and 
friends are taught by observation and ex- 
perience the beneficial effect of fresh air and 
proper hygienic living, both in the recovery 
and maintenance of health. While under 
treatment the patients are required to devote 
their entire time to it. 



126 



HOME TREATMENT 

Sleeping Arrangements 

The night should be passed either out-of- 
doors or in a large room with wide open win- 
dows; in the former case some of the many 
arrangements for out-door sleeping can be em- 
ployed. The patient should go to bed early 
and accustom himself to sleep from nine to 
ten hours. Indeed, life in the open air, as 
everyone has experienced, conduces to long, 
sound sleep. As a further preparation for 
sleep, the evening hours can be passed in a 
quiet, restful manner, so that 

"The cares, that infest the day, 
Shall fold their tents, like the Arabs, 
And as silently steal away." 

In sleeping out-of-doors during the winter, 
it is important that enough bed and body 
clothing should be used to make one com- 
fortable, — blankets, eider-down quilts, woolen 
pajamas, or a sleeping bag of some heavy 
woolen material, a hood or helmet for the 
head, and woolen socks, will accomplish this, 
and thus clad like an Arctic traveler, one can 
brave the severity of almost any winter's 
night and be comfortable. Those who are ac- 
customed to out-door sleeping speak with en- 
127 



TUBERCULOSIS 

thusiasm of the refreshing sensation when 
they awake in the morning. 

Exercise 

After a little time, when the treatment is 
well established and there is no fever, some 
exercise may be taken, but only upon the ad- 
vice of the physician. For the majority of 
patients, walking is probably the best and 
safest exercise, but whatever it is, it should 
never be violent or excessive. If it is walking, 
it should be leisurely and not fast enough to 
cause coughing, shortness of breath or fatigue. 
All exercises which require considerable ex- 
ertion and rapidity of motion, like horseback 
riding, tennis, bicycle riding, and the like, are 
unsafe, and many a consumptive has gone to 
his destruction by indulging in them. Games 
requiring little exertion, like croquet, are al- 
lowable. No exercise should be taken before 
or directly after meals. A good general rule 
is to take only so much exercise as does not 
interfere with the favorable progress of the 
disease towards recovery. " More consump- 
tives kill themselves," says a German author- 
ity, "by doing too much than in any other 
way." Lung gymnastics and deep breathing 
128 



HOME TREATMENT 

exercises for expanding the chest are some- 
times advised, but they should never be taken 
except with the sanction and under the super- 
vision of the physician. Many good authori- 
ties are opposed to all such exercises and con- 
sider them harmful: the diseased lung, they 
contend, like other diseased portions of the 
body, heals sooner by rest or the avoidance of 
all unnecessary exertion. As recovery pro- 
gresses, both greater physical and mental ef- 
fort may be allowed, for it must be remem- 
bered that the habits of confirmed invalidism, 
so fatal to future usefulness, may be formed 
while the " cure " is taking place. In certain 
sanatoria the inmates who are on the way to 
recovery are gradually accustomed to do a 
little more work, and a little and a little more 
severe, until by the time they have recovered 
they can do more or less of an ordinary day's 
work. 

Food 

Someone has said that " a consumptive who 
does not eat is a consumptive lost," and it is 
quite obviously true. No perfection of the 
open-air life will avail without good nutrition. 
Good and nutritious food in abundance, and 
129 



TUBERCULOSIS 

good digestion, are vital to the success of the 
open-air treatment. The test as to whether or 
not a patient is being properly nourished is 
a steady gain in weight until the normal is 
reached. If the digestion is good, a mixed 
diet consisting of proper proportions of the 
proteids, fats and carbohydrates, such as meat, 
vegetables, bread and butter, milk, eggs, va- 
rious fats, fish, fruit, soups, etc., taken at the 
usual times may be sufficient. If the weight 
and strength are deficient, probably the three 
meals will have to be supplemented by be- 
tween-meal lunches, consisting of milk, raw 
eggs, bread and butter, cocoa, chocolate, soup, 
etc. 

The food should be varied, well cooked and 
served in a tempting manner. The appetite 
is not always a safe guide. The main thing 
is to eat and digest the proper amount of food, 
for the appetite, like rumor, " grows by what 
it feeds on." Generally, however, the out- 
door life brings a keen desire for food. Milk 
is a most important article in the consump- 
tive's dietary, and most persons can take it, 
although one now and then thinks he cannot. 
It should be taken slowly or sipped. Some- 
times as much as three pints or more are taken 
130 



HOME TREATMENT 

daily in addition to the regular meals, particu- 
larly if the patient is below weight. Next in 
importance to milk are eggs, preferably raw. 
Fats in liberal quantities are generally essen- 
tial for the tuberculous patients and are fur- 
nished in the form of milk, cream, butter, 
bacon and olive oil. 

The kind and quantity of food, and the 
hours of taking it, must be carefully arranged 
by the physician, and it is often well for the 
patient to keep an exact record of his daily 
food as well as the number of hours he spends 
out-of-doors and the exercise he takes. An 
English authority declares that the important 
items of a consumptive's food should be or- 
dered in definite amounts and weighed out 
each day until by practice one has learned to 
guess at the amounts with sufficient accuracy. 
Simply to tell the patient to " feed up," as is 
frequently done, is a very inadequate concep- 
tion of this most vital part of the treatment. 
If the question of nutrition is dismissed in this 
off-hand manner, it will sometimes be discov- 
ered, too late, that the patient is " feeding 
down " to his destruction. One should rest 
an hour before the principal meals. 

It is not, of course, possible in all or many 
131 



TUBERCULOSIS. 

cases, to provide elaborate menus, or is it 
necessary, but in almost every household 
someone can be found, or trained, to prepare 
the essentials of a proper consumptive diet. 
With the study of a good cook book, or a 
treatise on dietetics, or a few lessons in a 
cooking school, one can learn to do this. 

Someone has called eating an act of wor- 
ship, and at this shrine must the consumptive 
worship with his whole heart if he would ob- 
tain salvation from his disease. 

Alcohol in any form is very rarely employed 
in the treatment at the present time, and 
should never be used unless prescribed by the 
physician. The best drink is pure water. 

The Hardening Process and the Cold Bath 

The open-air treatment may be regarded as 
a kind of " hardening " process, intended to 
increase one's general resistance to the disease. 
The continuous out-door life in itself, in all 
kinds of weather, and varying temperatures, 
particularly during the winter season of 
northern latitudes, is perhaps the most impor- 
tant part of this process. 

The application of cold water to the skin, 
the cold bath, further contributes to this 
132 



HOME TREATMENT 

hardening process. By its use the action of 
the skin is increased, the susceptibility to tem- 
perature and climatic changes lessened, the 
appetite improved, and the whole system stim- 
ulated. With a delicate person, one may be- 
gin with dry rubbing night and morning, either 
simply with a coarse towel, a rough hand 
glove, or by wrapping the patient in a coarse 
sheet and rubbing him over the sheet. Later, 
moist rubbings can be substituted by means 
of a wet coarse cloth, or by enveloping him in 
a wet sheet, beginning with a temperature of 
90 and gradually reducing it to 70 ° or 6o°. 
With many patients, perhaps the majority, in 
the early stages of the disease, a cool or cold 
sponge or shower bath can be begun at once. 
If, however, there is failure of reaction, indi- 
cated by chilliness, and a blueness of the skin, 
the bath must be modified or omitted. The 
test of the good effects of the cold bath is a 
quick reaction, a feeling of warmth and well- 
being, and an improvement of appetite, diges- 
tion and circulation. 

Dr. Minor of Asheville, North Carolina, 

gives an easy and simple method of taking 

a cold bath by the use of no more complicated 

apparatus than a tin tub, a bath thermometer, 

133 



TUBERCULOSIS 

a big sponge, salt and a rough Turkish towel. 
His method of procedure is as follows: One 
or two buckets of water and a handful of 
sea salt are placed in the tub, the water, on 
beginning the bath, being at a temperature of 
ioo° F., which is reduced a degree every day 
until 70 to 55 is reached. The patient sat- 
urates the large sponge with water, stands 
erect, holds it over his shoulders and neck, and 
squeezes out the whole volume at once, in a 
shower down his back and neck, thus produc- 
ing a douche. This is repeated rapidly over 
all parts of the body for about half a minute ; 
then the patient jumps out, rubs off briskly 
with the rough Turkish towel and at once 
dresses. Instead of the sponge, a pitcher of 
water can be used. 

There are many other methods of applying 
water for its stimulating and hardening ef- 
fect, such as the cold friction by means of a 
wet sheet, a wet pack, the douche and shower 
baths, but the one described above is the most 
simple and is within the reach of anyone. 

Clothing 

There is no special kind of clothing for the 
tuberculous individual different from that 
134 



HOME TREATMENT 

worn by any well person. He should be 
clothed so as to be comfortable, and no more 
than will accomplish this. Unduly heavy 
clothing has a tendency to relax the skin and 
produce profuse perspiration upon any slight 
exertion, rendering the body more sensitive to 
changes of temperatures, and more liable to 
catch cold. The clothing should be equally 
distributed over the body, and no greater 
thickness, such as chest protectors, or extra 
jackets, should be worn over the chest than 
elsewhere. The under garments should be 
woolen or merino which contains a certain 
proportion of cotton, and only of such weight 
as will keep one comfortable. They should 
be loose enough to permit a layer of air be- 
neath them that an equable temperature may 
be maintained. " Inside our dress," says 
Pettenkoffer, " we should carry the air of the 
South wherever we may be. We live in our 
dress like an unclothed tribe in a Paradisian 
country where the air is constantly calm and 
the temperature from 75 ° to 94 ." The un- 
der-clothing worn during the day should be 
removed at night and thoroughly aired. 
Women should wear short skirts : trailing ones 
are a menace both to themselves and those 
135 



TUBERCULOSIS 

about them from the dirt and dust they col- 
lect. 

Precautions and Mode of Life After Recovery 

As pulmonary tuberculosis is a disease, for 
the most part of in-door life, the out-door 
life is one of the principal factors, as we have 
seen, in the accomplishment of the cure. 
After recovery, therefore, the out-door life, 
so far as possible, should be continued. In- 
deed, very much the same general plan of life 
pursued during the treatment is to be the 
guide for one's subsequent mode of living. 
Sometimes it will be possible for one to adopt 
some out-door occupation, or, if the in-door 
life must be resumed, one can embrace every 
opportunity to spend a certain amount of time 
daily out-of-doors: for example, by walking 
to and fro from one's place of business, an 
evening walk, sleeping out-of-doors, and 
spending the holidays in the open air. 

The " night camp " is a recent develop- 
ment, by means of which the city worker who 
has recovered from tuberculosis can go out 
into the suburbs and sleep under fresh-air 
conditions impossible for him to obtain in the 
city. Upon a suitable open space, specially 

136 



HOME TREATMENT 

Resigned buildings are erected, where one can 
sleep with an abundance of fresh air or even 
out-of-doors, and after a good breakfast in 
the morning return to the city for his day's 
work. By this means it is hoped that many 
a relapse will be averted. 

In some instances an in-door occupation 
can, to a certain extent, be converted into an 
out-door one by working with open windows, 
and securing a free circulation of air. 

Especial precautions should be taken for 
several years after recovery, for if a relapse 
occurs it is more likely to happen within this 
period; indeed, the cure cannot be considered 
absolute until at least two or three years have 
elapsed. Excessive physical and mental ex- 
ertion is to be avoided as well as all excesses. 
If there are any indications of retrogression 
from the normal standard of health, such as 
loss of weight, strength, appetite, etc., the tem- 
perature should be taken for a number of days, 
and if any fever is present, treatment must at 
once be resumed. A cold, the " grippe," or 
any respiratory disease must receive imme- 
diate and careful attention. Sufficient rest, 
pure air, good food, the avoidance of over- 
exertion, and the general conservation of 
137 



TUBERCULOSIS 

energy are cardinal principles of living ever 
to be borne in mind by the cured consumptive. 
The objection may naturally be urged that 
to treat a case of tuberculosis with all the at- 
tention and detail outlined above would re- 
quire the command of considerable pecuniary 
means as well as one's entire time for an ex- 
tended period, and would, therefore, be be- 
yond the reach of many consumptives. True, 
the ideal plan of treatment does require both 
time and money : it could not be otherwise with 
a disease whose treatment depends upon the 
prolonged influences of hygienic measures to 
restore the lost power of resistance. From 
the ideal plan, however, modifications can be 
made according to the exigencies and limita- 
tions of the individual case; and it is better 
to have a standard and to come as near to it 
as one can, bearing always clearly in mind the 
great general principles of the treatment. 

A Suggestive Daily Routine 

The physician, after a painstaking examina- 
tion of the patient and a careful considera- 
tion of his individual cordition, alike as to his 
disease, his environment, and social and pe- 
cuniary state, prepares a plan of treatment in 

138 



HOME TREATMENT 

detail, and thenceforth exercises a constant 
and close supervision over him. Nothing is 
left to chance or the caprice of the patient. 
The physician must command and the patient 
must co-operate with him and obey. The fol- 
lowing is a suggestive daily routine, such as 
the physician prepares, for an average patient 
in the early stage of the disease, whose general 
physical condition is good and who has no 
fever. 

7 or 7.30 A. M. Arise and take a cool or 
cold sponge bath in a warm room, and then 
dress. On awakening or while dressing, a 
glass of hot milk, bouillon, a cup of weak 
coffee with cream, or cocoa may be taken as 
directed. 

7.30 or 8 A. M. Breakfast, which is a 
substantial one, consisting, for example, of 
weak tea, coffee or cocoa, a cereal with cream 
and sugar, some meat, or bacon with eggs, 
bread and butter, and milk. 

8 or 9 to 11 A. M. Rest in the reclining 
chair and whatever exercise is ordered. 

11 A. M. A glass of milk, a raw egg or a 
light lunch of some kind if ordered. 

11 to 12 M. Rest or exercise as ordered. 

12 to 1 P. M. Rest in the reclining chair 

139 



TUBERCULOSIS' 

out-of-doors, or in one's room with open 
windows. 

1 to 2 P. M. Dinner of a liberal mixed 
diet, consisting of soup, meat, vegetables, 
bread and butter, milk and some simple des- 
sert, and fruit. 

2 to 2.30 P. M. Rest. 

2.30 to 4 or 5 P. M. Rest in the reclining 
chair or a walk if ordered, shorter than in 
the forenoon. 

4.30 or 5 P. M. A light lunch of milk, etc., 
as in the forenoon. 

5 to 6 or 6.30 P. M. Rest as before dinner. 

6 or 6.30 P. M. Supper, which should be 
a substantial one. 

7 or 7.30 to 9 or 9.30 P. M. In a well- 
ventilated room, or upon the piazza when the 
weather permits. 

9 to 10 P. M. Retire, and just before re- 
tiring a glass of milk. 

The lunches may be omitted if the nutrition 
and weight are satisfactory. 

Of course the above day's plan is subject 
to change as indications arise, according to the 
discretion of the physician. 

The weight is to be taken every week. 

Thus, it will be seen that to get well of 
140 



HOME TREATMENT 

tuberculosis requires the persistent and con- 
tinued adherence to a strict daily routine, but 
the habit is soon established, and one is sus- 
tained by the reasonable expectation of a suc- 
cessful result, if he perseveres in the treat- 
ment. 
Some Aphorisms for the Tuberculosis Patient 

1. " The labor which best repays a sick man 
is to get well." 

2. "Desire but one thing" (to get well) 
" and that with all the heart." 

3. " Whatever thou takest in hand remem- 
ber the end, and thou shalt never do amiss." 

4. " Whatever is worth doing is worth doing 
well." 

5. " Where sunlight enters not there the 
physician goes." 

6. " He that taketh heed shall prolong his 
life." 

7. " Life is not to live, but to be well." 

8. " He who has health has hope, and he 
who has hope has everything." 

9. " Be intent only on that which thou art 
now doing and on the instrument by which 
thou doest it." 

10. " Your most important duty is to get 
well. Let all other duties be secondary." 

141 



IX. TUBERCULOSIS AND CLIMATE 

VJ^^JUBERCULOSIS is no respecter 
m £*\ of climate, but " extends over 
Bl 1 every part of the habitable globe." 

^^^^^ " It is," as has been said by Prof. 
Hirsch, " emphatically a disease of 
all times, all countries, and all races. No cli- 
mate, no latitude, no occupation, no combina- 
tion of favoring circumstances forms an 
infallible safeguard against its onset." Cold 
or dampness does not produce it, or warmth 
prevent it, for neither one nor the other de- 
stroys the tubercle bacilli, and when a favora- 
ble soil in the individual exists and he is 
exposed to the bacilli a sufficiently long time, 
he will contract the disease in whatever cli- 
mate he may be. 

One would, however, naturally suppose that 
in those regions where the climate is " favor- 
able," as we say, permitting a constant out- 
door life, the opportunities for being brought 
in contact with the germs would be less, and 
the conditions for resisting them more favor- 
able. Such undoubtedly would be the case 
142 



TUBERCULOSIS AND CLIMATE 

and, indeed, has been found to be so provided 
other conditions, such as sufficient and whole- 
some food, pure air at night as well as day, 
and, in general, good hygiene and sanitary 
conditions, prevailed. For example, a person 
living a wholesome life on a ranch in South- 
ern California, Colorado or New Mexico, 
where abundant sunshine, pure air, dryness 
of atmosphere, and but little rain were the 
climatic characteristics throughout the year, 
would probably be less likely to contract tu- 
berculosis than upon a New England farm 
where the weather conditions in the winter 
and spring were distinguished by much cold 
moisture, frequent storms of snow or rain, 
and much cloudiness, compelling one to pass 
a very considerable amount of time in-doors. 
And the same argument holds good in the 
treatment of tuberculosis, other things being- 
equal, as we shall later discuss. " If sunlight 
is good at all," says Dr. Knight, " why isn't 
it better to have twenty-five or more days of 
it per month than to have ten or twelve or 
less?" 

Unhygienic Conditions in Cities 

In the cities, however, unfavorable hygienic 
143 



TUBERCULOSIS 

conditions, particularly overcrowding, poor 
nutrition and impure air at night exercise 
their baneful influences just as surely in the 
favorable as the unfavorable climates. For 
example, in the South and in the tropics 
where the climate favors a constant out-door 
life, tuberculosis is one of the most frequent 
diseases in cities situated in these regions, as 
in Havana, Rio Janeiro, Alexandria, Egypt, 
etc. In the high altitudes, which were sup- 
posed to be particularly free from tuberculosis, 
as well as favorable for its cure, densely popu- 
lated cities, like Mexico City, Bogota, Quito 
in South America, etc., again show a large 
mortality from tuberculosis. In Bogota the 
persons affected by tuberculosis were found 
to belong to the lowest and poorest class of 
the population who lived in most unfavorable 
hygienic conditions. A good climate will not 
counteract bad living conditions. 

So long as the Indians led a nomadic life 
on the Western plains, they rarely suffered 
from tuberculosis, but when they changed 
this free life for a confined one in barracks, 
and lived in closely settled communities, they 
readily contracted the disease and suffered 
severely from it. In a community of 400 
144 



TUBERCULOSIS AND CLIMATE 

Apache Indians taken from a free nomadic 
life in Arizona and New Mexico and trans- 
ferred to Alabama, where they occupied log 
cabins, the deaths from tuberculosis in rive 
years was 78, or 43J per cent, of the total 
number. " In his original life," says Com- 
missioner Leupp, " the Indian had no per- 
manent home, and his pursuits were all such 
as kept him out-of-doors and hardened his 
body. When his tepee became surrounded 
with filth, he moved it to a fresh spot. He 
wore little clothing — in some places almost 
none. Exposure to the open sunshine, a 
hardy meat diet, and a scattered and ever- 
moving population were pretty sure defense 
against germs. Times have changed. The 
Indian can no longer roam everywhere at 
will. He overburdens his body with modern 
clothing. He has been taught to live in a 
cabin, in which he nails down the few win- 
dows, caulks the cracks and sets up a stove 
which he heats red-hot. In the one or two 
rooms of this dwelling he eats, sleeps, rears 
his family, entertains his large circle of 
friends — expectorates, sickens and dies. All 
the conditions are perfect for the spread of 
tuberculosis. In due course of time his com- 
145 



TUBERCULOSIS 

munity becomes a nest of infection for the 
larger white community that is fast growing 
up about him." In the islands of the West 
Indies, tuberculosis is very prevalent among 
the colored population, though they live an 
out-of-door life under sunny skies. This is 
largely due, it is believed, to the habit they 
have of shutting themselves up tightly at 
night in their crowded cabins from an unrea- 
soning fear of night air. 

Among the Scandinavians in the country 
regions of Minnesota tuberculosis is said to 
be more prevalent than in the cities of that 
state, and the cause is attributed to the fact 
of their in-door life without proper ventila- 
tion during their long, cold winter. The cold, 
dry climate of Minnesota is a wholesome one, 
and was regarded as favorable for the cure 
of tuberculosis, but it is powerless against 
in-door life and impure air. 

Consumption Rare in Out-Door Life 

Any favorable climate must be utilized to 
be beneficial, and an unfavorable one, if 
rightly made use of, by breathing fresh air 
day and night, is of far more value in main- 
taining one's health or in the recovery from 
146 



TUBERCULOSIS AND CLIMATE 

tuberculosis. We see, then, that it is not alone 
the climate of a place which is conducive to 
tuberculosis or its cure, but the way people 
live in that climate. 

" There is a vast mass of evidence," says 
Lindsay, " which conclusively proves that con- 
sumption is comparatively rare among those 
who follow an out-door life under normal and 
healthy conditions; that it is comparatively 
common among those who live habitually in- 
doors, and that it attains its maximum inci- 
dence among those whose occupation involves 
prolonged confinement in a vitiated atmos- 
phere." 

In the treatment of tuberculosis, climate 
has played an important role, more so in the 
past perhaps than at the present time. (Experi- 
ence in sanatoria, which have been established 
in all kinds of climates, as well as experience 
in the home treatment, has taught us that any 
climate where the air is pure and free from 
dust, and there is protection from high winds, 
is favorable for the treatment of the disease. 
Dettweiller, who established the famous sana- 
torium at Falkenstein in Germany, which pos- 
sesses a climate much like that of New Eng- 
land, once told the writer that he could cure 
147 



TUBERCULOSIS 

tuberculosis in any climate, and surely his 
success in his own sanatorium has proved his 
statement. 

Climate Only One Factor 

It is the combination and painstaking appli- 
cation of all the several units of the open-air 
treatment which bring success, and not climate 
alone, upon which so great reliance was for- 
merly placed. Careful medical supervision, 
rest, proper and abundant nourishing food, 
mental repose, and, in brief, the most careful 
regulation of the patient's life, are as essential 
as climate. " Is there not, then," one natu- 
rally asks, " any value in what are called fav- 
orable climates for the consumptive, such as 
those of Colorado, Southern California, the 
southern pine belt, Asheville, the Adiron- 
dack?, and many others at home and abroad ? " 
Long experience has shown that " favorable " 
climates do have an added value in the treat- 
ment over what we might call the indifferent 
or unfavorable climates, such, for example, 
as that of New England in the winter, pro- 
vided always that the other factors in the 
treatment are at hand. 

The great mistake so often formerly made, 
148 



TUBERCULOSIS AND CLIMATE 

and which has brought discredit upon cli- 
mate, was attributing to it more than it could 
alone and unaided perform. The consump- 
tive was so often told to change his climate, — 
go to this or that health resort and there stay 
until he got well or worse. He was left in 
ignorance of the importance of the other steps 
in the treatment, or if he had some inade- 
quate conception of them, it remained with 
him to carry them out when and how he 
pleased, or not at all. If he did not improve 
under these conditions, it was not the climate 
that was at fault, but a disregard of the other 
equally important factors in the treatment. 
" If I were afflicted with tuberculosis," says 
Dr. Pottenger, " I would rather be treated in 
an intelligent manner in the most unfavorable 
climate than undertake to regain health alone 
in the best climate on earth. However, I be- 
lieve my chance of cure would be materially 
increased, if, combined with intelligent treat- 
ment, favorable climatic conditions were also 
present." 

By the climate of any place, we mean the 

average weather conditions of that place, 

which are the temperature, humidity, the 

movement of the atmosphere (the wind), the 

149 



TUBERCULOSIS 

condition of the sky as to clouds, fog., rain or 
snow. By weather, we mean these conditions 
observed at a particular time ; thus, the winter 
climate of northern Xew England is cold, 
more or less damp, with a considerable snow 
fall, and a good deal of cloudiness; but the 
zceather of any particular winter may be com- 
paratively mild with little snow. 

The Most Favorable Climate 

The kind of climate which it has been 
found is most favorable for tuberculosis is 
one which affords a large number of pleasant 
sunny days; is dry; is not subject to frequent 
and extreme changes of temperature, or to 
high winds, and which has a pure atmosphere 
as free from dust as possible. It has also 
been found that a cool or cold climate, such 
as the Adirondacks in winter, gives better re- 
sults than a warm climate; the stimulating 
influence of the cold is of value. 

After a careful investigation, a committee 
of experts of the National Tuberculosis As- 
sociation came to the following conclusions 
regarding the value of the different climatic 
elements in the treatment of tuberculosis, 
which, perhaps, as nearly expresses the truth 
150 






TUBERCULOSIS AND CLIMATE 

upon this subject as it is possible to reach at 
the present time. They place first, of course, 
pure air, and, next, sunshine. " The indirect 
effects of sunshine," they say, " as seen in the 
powerful stimulation of the patient's spirits, 
is of great importance." Dryness of the air 
is placed next, and is regarded as a most im- 
portant factor. Equability of temperature is 
not considered of importance, except in th'e 
case of elderly persons or the very feeble. 
Wind they consider only harmful when the 
patient is directly subjected to it. Altitude, 
as in the mountain resorts, such as in Colo- 
rado or Switzerland, is regarded of more or 
less value on account of the greater purity of 
the air, and the stimulating effect upon the 
appetite and nutrition. " On the whole," con- 
tinues the report, " low relative humidity 
(dryness) with moderately low or low tem- 
perature is most generally suitable, and the 
average tubercular patient always makes his 
best gains in cold, dry weather where such 
conditions prevail." 

Another influence of a favorable climate, 
sometimes forgotten, is the comfort and hap- 
piness of the patient. To make the " cure " 
under sunny skies, with the stimulating effect 
151 



rvizj. :vi:s:s 

c: a dr.-. clem arr:sr.here an: rre irsrirarcn 
c: rleasirg scerery. is crvicusly less :: s. :15k 
arr ::'.'■:'.'■ t: less rr:r:::r rhar :ak irr rhe 
tres.rr.er.: ir 1 ckrra:e :: s::rr:s. r.u:: iir:;- 
ress ari c:e; :r ierarre :: clcriy vrearrer. 
Cr:e: chirrs zeirz ezrai. :re ~:r'.i rrefe: :: 

crrra:e :: Iclerai:-. -~e~ Vex::: :r Aiker, 
5. C .. than in rhe cloudy one g: New Eng- 
land. A man is happier and more contented 
ir. :he srrshire rhar ir r:e :l:r: : ri r.rrerr- 
ment goes a long ways in the " cure." Indi- 
viduals arriving in a climate, it is where 
the sun is obscured by fogs and clouds for 
weeks if a re suffer depression of s;iri:s. 
loss ::' appetite, digestive disturbances and 
rrrre-sickress. 

Why a Chaise cf Clinate 



:e:::e :::ere "."ere ary sara::r.a .:: 
a rrarre :: :li:ra:e ::• ::::.:• 
ly rrlrz v.- rich crerel = ry r::sre:t 
ment or cure to the tuberculous 
:. ger.era.ly. a "arrr srrrr.er :li- 
Florida or Bermuda, was chosen. 
: ■-: 



TUBERCULOSIS AND CLIMATE 

The disease was often not detected until it 
was well advanced and the patient was hav- 
ing active symptoms, such as cough, fever, 
chills, and night sweats, and, in consequence, 
had become much enfeebled. Or, if discov- 
ered early, it was not considered serious until 
these symptoms occurred, particularly the 
cough. Under these conditions, it was very 
natural to select a warm, sunny climate where 
one could be made comfortable out-of-doors 
with very little exertion on his part. Comfort 
was obtained and life prolonged in some cases, 
but rarely was the disease cured or arrested; 
generally the poor patient came home to die. 
Later, after the warm climates lost their popu- 
larity, the high altitude climates came into 
notice, and in this country Colorado became 
the Mecca for consumptives, and in Europe 
Davos became famous as a tuberculosis 
health resort and remains so to this day. 

At the present time, if the disease is in an 
advanced stage, the consumptive is advised 
to remain at home as the most suitable place 
for his condition. 

Selection of a Climate 
If the disease is in the early stage, without 
153 



TUBERCULOSIS 

fever, and a change of climate is considered 
desirable, such a one is selected as will, in 
conjunction with the other factors in the open- 
air treatment, offer the best prospects of cure. 
The patient either goes to a well-conducted 
sanatorium in the resort selected, or else is 
put under the care of an experienced physi- 
cian who carefully and constantly keeps him 
under supervision. Under such conditions 
many cures are effected and climate is made 
valuable. 

When the change of climate is under con- 
sideration, the following points must be care- 
fully determined: 

First: The exact physical condition of the 
patient and his disease, — is it a suitable case 
to send away? 

Second : What is the climate best suited 'to 
him and the stage of his disease? 

Third: The sanitary condition of the re- 
sort selected; the accommodations; possibili- 
ties of obtaining proper food; and a reliable 
local physician. 

Fourth: The material condition of the 
patient: can he make the change without 
pecuniary worry? 

Fifth: The influence of the change of cli- 
154 



TUBERCULOSIS AND CLIMATE 

mate upon the relatives or friends who may 
accompany him. 

When once the resort which seems best 
adapted to the case has been selected, the 
name and address of a reliable physician at 
the resort is to be obtained, and the patient is 
to be placed under his guidance and control. 
Any attempt of the home physician to control 
or direct the treatment at a distance is unsat- 
isfactory and unfair to the patient. 

A change of climate is a serious matter, 
requiring a knowledge of climate and health 
resorts on the part of the physician, and 
should be advised only after careful considera- 
tion of all the factors in the case. Unfortu- 
nately, the patient sometimes makes a change 
on his own responsibility or on the advice of 
friends, — a dangerous thing to do. It may 
happen to be right, but it is more likely to 
work irreparable injury. 

There are many so-called health resorts 
which possess to a greater or less extent the 
elements of climate which, as we have seen, 
are regarded as especially favorable for the 
treatment of tuberculosis. There are those of 
greater or less altitude, and those at or near 
sea-level; some with a cold, rigorous winter 
155 



TUBERCULOSIS 

climate, others with a comparatively mild one ; 
some that are winter resorts only, and others 
that are serviceable all the year. 

The Essential Climatic Factors 

When any health resort is under considera- 
tion as applicable to a case of tuberculosis, 
we must first learn the essential climatic facts 
of the resort in order to form an opinion as to 
its availability. 

First, Temperature: We must know the 
average daily temperature for the season in 
which one visits the health resort : if a winter 
resort, the average winter temperature; if an 
all-the-year resort, the average temperature 
for the whole year. Then, it is important to 
know the average daily range of temperature 
in order to judge of the equability of the 
climate. Again, we want to know what ex- 
tremes of heat and cold have occurred in the 
resort in the past ; for these extremes of tem- 
perature, as Dr. Richards has well put it, are 
the "chances the invalid has got to take in 
any resort; they do not indicate what tem- 
perature he may expect, but what it may be 
his good or evil fortune to encounter." 

Second, Humidity: The humidity is an- 

156 



TUBERCULOSIS AND CLIMATE 

other important factor to determine in order 
to judge of the dryness of the atmosphere. 
Next comes the average rainfall; the direc- 
tion and velocity of the wind; and, finally, 
what we may call weather data, namely, the 
average number of clear, fair, rainy, and 
cloudy days. This enables us to determine 
the amount of clear sky and sunshine one may 
expect at the resort, and hence the degree of 
out-door life one can enjoy. If the resort is 
one in the snow belt, like Saranac, or Davos 
in Switzerland, it is important to know the 
amount of snowfall and the length of time 
snow lies continuously on the ground, and 
when it begins to melt in the spring. 

Third, Land Configuration: We must also 
learn something of the form of the land, — 
whether level, hilly or mountainous. A hill 
or mountain affords protection from high 
winds. Moderate ascents are often of value 
for exercise, as Brehmer utilized them at 
Goerbersdorf for his consumptives. 

Fourth, Soil : Again, we desire to know the 
character of the soil, and the kind of vegeta- 
tion; whether the region is well-wooded or 
not, and the character of the forests. The 
fir, pine, spruce and other evergreen trees are 
157 



TUBERCULOSIS 

generally considered an advantage to a health 
resort on account of their shade and balsamic 
exudations. 

Fifth, Facilities for Comfortable Living: 
There are other essential qualifications than 
those of a purely climatic character which 
should be possessed by a health resort. For 
example, it is important for the invalid to 
know what facilities exist for comfortable 
living : that the water is pure and the sanitary 
conditions good, and the board of health ef- 
ficient. He should know that the house he 
is to live in has been efficiently disinfected, if 
it has been previously occupied by a consump- 
tive. He should also find out whether or not 
he will be received into the hotels or even the 
resorts, for many places dislike the presence 
of consumptives and many hotels will not re- 
ceive them. 

Various Health Resorts in America 

There are many resorts in this country 
which have proved their value in the climatic 
treatment of tuberculosis and which still re- 
tain their popularity. The Adirondacks have 
become widely known, principally through 
Dr. Trudeau and the sanatorium he estab- 

158 



TUBERCULOSIS AND CLIMATE 

lished at Saranac. Asheville, North Carolina; 
Colorado Springs and other places in that 
state; Southern California; the dry pine belt 
of the South as represented by the well-known 
resort of Aiken; New Mexico; Arizona; and 
many other places in the great Southwestern 
plains and uplands, all possess favorable cli- 
matic elements for the open-air treatment of 
tuberculosis and have been extensively em- 
ployed for this purpose. 

The warm, moist climates, like the coast of 
Florida, Bermuda, and various islands in 
southern latitudes, are not now regarded as 
suitable for the effective treatment of tuber- 
culosis: they are too enervating, and do not 
possess that stimulating quality which aids 
appetite and nutrition. Long ocean voyages, 
once much in vogue with the English, are now 
rarely advised. The air of the ocean is of 
great purity, it is true, but the obvious disad- 
vantages of an ocean voyage render this 
method of obtaining the pure air far inferior 
to favorable climatic resorts on land. 



159 



TUBERCULOSIS 

Health Resorts in Europe 

In Europe the best-known climatic resorts 
are in Switzerland, the Black Forest and 
Mountains of Germany, and the Riviera. 
Davos, which has already been mentioned, is 
the most popular high-altitude resort, more 
frequented in the winter season, when the 
snow, which covers the ground for a long 
period, conduces to the purity of the air. The 
situation of Davos, however, in a narrow val- 
ley, renders the days very short in winter, the 
sun not appearing until about ten o'clock in 
the morning and setting about four in the 
afternoon. The Riviera on the shore of the 
Mediterranean Sea has for many years been 
a great winter resort for consumptives. 
The climate, however, is uncertain and the 
" mistral," the north wind, blows violently 
at times. There is much sunshine never- 
theless, and the attractiveness of the sea 
and land scenery is most delightful. There 
are many resorts in the highlands of Ger- 
many, in the Black Forest, the Bavarian 
and Hartz Mountains and the Tyrol, and 
many sanatoria have been established in these 
regions. The only very dry warm winter 
1 60 



TUBERCULOSIS AND CLIMATE 

climate near at hand to Europe is that of the 
Egyptian desert. It exhibits the climatic 
characteristics of arid regions in low altitudes, 
warmth, great purity of air, continuous sun- 
shine, great daily variations of temperature, 
dryness of the atmosphere, and little or no 
rain. It is comparable in this country to 
Southwestern Arizona. Helouan, Luxor and 
Assouan are the principal resorts. 

Dr. Knopfs Ideal Climate 

Dr. Knopf has in a single sentence well 
summed up the whole question of the climatic 
treatment of tuberculosis. He says : " The 
ideal climate for the average pulmonary pa- 
tient, in the earlier and more hopeful stages 
of the disease, is the one where the extremes 
of temperature are not great, with the purest 
atmosphere, relatively little humidity, much 
sunshine, and all the conditions which permit 
the patient to live comfortably out-of-doors 
the largest number of days out of the year 
and the largest number of hours out of the 
twenty-four." 

A favorable climate is a valuable aid in the 
treatment of tuberculosis, but it must at the 
same time be accompanied by all the other 
161 



TUBERCULOSIS 

factors in the open-air treatment: competent 
medical supervision, abundant and good food, 
rest, and all the hygienic conditions requisite 
for the " cure." Unless this is the case, cli- 
mate will prove but an elusive hope. 



162 



X. THE PREVENTION OF TUBER- 
CULOSIS 

Q RESIDENT ELIOT in an ad- 
dress to doctors upon " The Com- 
ing Change in the Medical Pro- 
fession," made the following 
prophetic remark : " The proba- 
bility is that the great part of the work of 
medical men is hereafter to be done in pre- 
ventive medicine." In regard to tuberculosis, 
preventive medicine is already a fact, and in 
the present world-wide crusade against tuber- 
culosis the pre-eminent aim is prevention. 

Even in the treatment, our efforts are 
directed towards the -early detection of the 
disease not only on account of the better 
results obtained, but quite as much because 
detected and cured at their early period, when 
it is a "closed " case, before the bacilli occur 
in the sputum, we prevent it from becoming 
a source of danger to others. 
163 



TUBERCULOSIS 

Two different lines of attack are employed 
in the work of prevention : the one we may 
call the direct against the germ itself, — the 
control of the tuberculous individual and his 
sputum, which is the direct source of danger; 
the other we call the indirect, which has for 
its aim the elimination of conditions which 
prepare the favorable soil for the seed, the 
tubercle bacillus. This includes all the vast 
and varied efforts to improve the social and 
living conditions of the masses, and so to raise 
and maintain their power of resistance to the 
infecting germ. Every movement in this 
direction is a distinct and definite step in the 
direction of prevention. 

The Direct Attack 

Since, as we have learned, the principal 
source of infection is derived from the sputum 
of a consumptive either expectorated or 
coughed out, obviously our first effort is to 
control this primary source of infection. If, 
indeed, each and every consumptive with 
bacilli in his sputum could be absolutely con- 
trolled and made a safe consumptive as re- 
gards others, tuberculosis would speedily 
begin to diminish and continue to do so with 
164 



ITS PREVEXTi; 

increasing rapidity, for we should be con- 
stantly reducing the supply of the infecting 
material. This, however, is obviously impos- 
sible, although effort in this direction is 
steadily increasing, as we shall later see. The 
difficulty still is that we cannot find out all 
the tuberculous individuals in any community. 
Many of them do not themselves know that 
they have the disease, and even if we could 
discover all cases, the difficulties of controlling 
them are well-nigh insuperable. We can, 
however, through educational means, accom- 
plish much by teaching the consumptive to 
control himself and by affording as free and 
easy an opportunity- as possible to every one 
to find out whether or not he has tuberculosis. 
In some cases an examination of the lungs 
can be required as a condition of employment, 
for example, as is already done in some estab- 
lishments. Education in the simple facts of 
tuberculosis has already accomplished much 
in this direction. 

The Educational Campaign 

The educational campaign against tuber- 
culosis has now become a mighty movement. 
In everv civilized country of the world the 

165 



TUBERCULOSIS 

people are now being taught what causes 
tuberculosis and how to avoid it. They are 
learning that the sputum carelessly scattered 
about and becoming dry is the cause of the 
disease, and that if this is destroyed before 
it becomes dry, the disease cannot be con- 
veyed to another. Such tuberculosis educa- 
tion, then, is one form of direct attack, for it 
teaches, as we have said, the consumptive to 
control himself and the non-consumptive to 
control his careless consumptive neighbor, or 
see that he is controlled. 

The method of conducting this great edu- 
cational propaganda is familar to all; almost 
every device is employed which will attract 
and interest the public. 

The Tuberculosis Exhibition 

The most generally popular method has 
been the tuberculosis exhibition, which has 
grown from small beginnings to the great in- 
ternational one exhibited in Washington in 
connection with the International Congress 
on Tuberculosis in 1908. Here was shown 
in the most extensive and graphic way what 
the various states of this country and the 
nations of Europe are doing in the prevention, 
166 



ITS PREVENTION 

study and cure of tuberculosis. It was a mar- 
velous exhibition, and one could spend weeks 
in its study. Later, when it was moved to 
New York, no less than 753,301 persons 
visited it during the seven weeks of its stay 
there. One can gain some idea of its magni- 
tude from the fact that it took ten special cars 
to transport it from Washington to New York. 
One striking feature of the exhibition is worth 
while mentioning just here. Against a board 
suspended between two balconies were three 
incandescent lights, which at regular intervals 
for an instant were extinguished and then 
flashed out again. Under the lights was this 
sentence : " These lights go out every two 
minutes and thirty-six seconds. Every time 
the lights go out someone dies of tuberculosis. 
Tuberculosis is communicable, curable, pre- 
ventable." There was always a group of 
people in front of this design silently watching 
the lights. 

The Traveling Exhibition 

Smaller exhibitions go from state to state 

and city to city, some under the auspices of 

the National Tuberculosis Association, and 

others under local or state associations. These 

167 



TUBERCULOSIS 

" traveling exhibitions " consist of charts, 
photographs, maps, models, diagrams, legends, 
and, in brief, a great variety of material illus- 
trating the study, prevention and treatment of 
tuberculosis. Such exhibitions are well ad- 
vertised beforehand in the local press, etc., 
and during the time of exhibition lectures are 
given, often with stereopticon illustrations, 
and literature distributed free. Every effort 
is made to arouse the interest of all the people 
in the city visited. In some exhibitions a 
phonograph with its tireless, if strident and 
monotonous voice, repeats tuberculous apho- 
risms. 

In the traveling exhibit of the Boston 
Tuberculosis Association was a realistic repre- 
sentation of two rooms side by side : one, a 
dark, dirty, disordered tenement house room, 
wretched in the extreme; and the other, a 
neat, clean, simply furnished room, with the 
fresh air and light coming in through the 
window. One is labeled " The wrong kind of 
a room," and the other " The right kind of a 
room." This feature of the exhibit always 
attracts much attention. On one occasion a 
little girl, after silently looking at both rooms, 
remarked to her father who was with her: 
" Papa, our rooms look just like this one " 
(pointing to "the wrong kind of a room"). 
1 68 



ITS PREVENTION 

" We've got to move, or we will all die of 
consumption." 

Moving picture plays are now employed to 
illustrate various phases of the tuberculosis 
problem, and the motion picture and vaude- 
ville theaters have been utilized for brief illus- 
trated talks upon tuberculosis. In the summer 
of 19 12, a seven-minute illustrated lecture upon 
" An Out-door Life for Health " was given in 
32 motion picture theaters in Boston, 340 times 
to a total number of 143,635 persons. 

The Service of the Public Press 

The public press has entered into the educa- 
tional campaign with great zeal and has im- 
mensely aided the movement. Through the 
press service of the National Association 
timely articles upon tuberculosis are furnished 
the newspapers of the country. From recent 
statistics collected by the National Associa- 
tion, the various newspapers of the United 
States printed articles concerning tuberculosis, 
which, when measured, amounted to over 
50,000 column inches of space in two weeks. 
If all this matter were gathered together at 
one time, it would make a newspaper of the 
ordinary size, of 359 pages of solid printed 
matter, without any advertisements, all on the 
subject of tuberculosis. If it were arranged 
169 



TUBERCULOSIS 

in one long chain, it would make a single 
column four-fifths of a mile long and two and 
one-quarter inches wide. Tuberculosis, then, 
is receiving " half a mile of publicity a week," 
as the National Association says. 

Popular illustrated lectures, pamphlets, leaf- 
lets, illustrated placards, issued by states, 
cities, boards of health and tuberculosis asso- 
ciations, still further disseminate tuberculosis 
knowledge, so that it would seem that soon 
every individual must have learned the simple 
facts concerning the prevention of tubercu- 
losis. School books on physiology and hy- 
giene now include the subject of tuberculosis, 
and in the State of Massachusetts, and per- 
haps in others, instruction upon the preven- 
tion of the disease is required by law to be 
given in all public schools. 

Compulsory Notification 

Another direct means of attack is compul- 
sory notification, that is, a law requiring all 
physicians and hospitals to notify the board 
of health of every case of tuberculosis coming 
under their observation, on the ground that 
tuberculosis is a contagious disease and there- 
fore dangerous to the public health. Such 
compulsory notification is now required in a 
number of states and practically all the larger 
170 



ITS PREVENTION 

cities in this country and in various countries 
abroad. The object of this requirement is to 
enable the health authorities to locate the 
cases of tuberculosis and keep them under 
supervision. This applies more particularly 
to crowded living localities where the dangers 
of infection are greatest. This law requiring 
notification is not intended to disturb the con- 
sumptive, but to make sure that he and his 
family are properly instructed as to the care 
of the sputum and the avoidance of infection, 
— it helps the consumptive and protects his 
family. 

Another important means of prevention is 
the free examination of suspected sputum in 
state and city laboratories, as has been before 
referred to. If the sputum is found to con- 
tain the tubercle bacilli, the health authorities 
are thus informed of the existence of the case 
and where it is situated. 

Again, laws and ordinances against indis- 
criminate spitting in public places is a pre- 
ventive measure. Some of the dangers from 
this vulgar habit have been already considered. 
If a consumptive is obliged to go about, he 
can provide himself with a pocket flask, or 
some pieces of cloth or Japanese napkins, 
which, after being used, can be deposited in 
a paper or rubber bag; or one can have a 
171 



TUBERCULOSIS 

rubber-lined pocket, and on returning home 
the sputum can be burned. 

It has been found that laundry workers 
suffer severely from tuberculosis, probably 
through infection from contaminated linen: 
hence, the importance of first boiling all ar- 
ticles before being handled or washed. With 
a known consumptive, all his soiled linen 
should be put in a bag by itself and boiled. 

The Tuberculosis Dispensary 

The free tuberculosis dispensary, a com- 
paratively modern development in the warfare 
of prevention, is an instrument of preventive 
medicine, the value of which, as Dr. Philip 
of Edinburgh, who established one of the first 
institutions of the kind, says, it would be dif- 
ficult to overestimate. Its value is not so 
great in treating the poor consumptive, im- 
portant as that is, as it is in protecting his 
family and the community. The dispensary 
affords a free and easy opportunity to every 
poor person for an examination of his lungs 
if he suspects he has tuberculosis. In this 
way many early cases are discovered and given 
timely treatment. "When a case is discovered, 
the visiting nurse goes to the patient's home, 
investigates the hygienic conditions, shows the 
patient how to live so as not to endanger 
172 



ITS PREVENTION 

other members of the household, and, what is, 
perhaps, the most important part of all, urges 
all the members of the family to be examined 
at the dispensary. Thus other cases in the 
same home are not infrequently discovered. 
This home inspection is repeated periodically, 
and the consumptive is never lost sight of. 
From the view-point of prevention, the protec- 
tion of the consumptive's family is the chief 
consideration. Almost every city now con- 
tains one or more such dispensaries, and some 
of them are opened at night for the accommo- 
dation of those who have to work by day. 

The Isolation of the Dangerous Consumptive 

Do what we will through education and the 
dispensary, with its visiting nurse and home 
supervision, there will always remain a cer- 
tain number of consumptives who are far 
advanced in the disease and in a hopeless 
condition, who, through ignorance, helpless- 
ness or wilfulness will not safely dispose of 
their sputum and who thus expose to the in- 
fection other members of the household. Such 
cases are always found in the homes of the 
poor. What shall we do with these sources 
of infection? The only way is to remove 
them to consumptive hospitals and thus isolate 
173 



TUBERCULOSIS 

them. This is no hardship to the poor bed- 
ridden consumptive, for he will receive far 
better attention than in his miserable home. 
" The advanced consumptive," says Dr. 
Jacobi, " is the real danger to the family and 
community. A dying consumptive should be 
removed to a healthy, comfortable place to 
die in without endangering the community; 
this is the only way in which the epidemics of 
chronic diseases may become extinct." 

Mr. Schiff, President of the Montefiore 
Home, declares that the isolation of phthisis 
sufferers in an advanced stage should be 
made compulsory by law. It is well known 
that no general hospital will now receive in 
its wards persons suffering from tuberculosis 
on account of the danger of infecting other 
patients; therefore, especial hospitals must be 
established for the advanced consumptive, and 
such hospitals are the greatest need in the 
United States at this time, and this is being 
done in a number of States by the establish- 
ment of local consumptive hospitals, as in 
New York, Minnesota and Massachusetts. 
The state sanatorium has been and is a more 
popular movement, but the greater need from 
the point of prevention is consumptive hos- 
pitals for the advanced and dangerous cases, 
whose isolation will undoubtedly do more to 

174 



ITS PREVENTION 

prevent and control the disease than any other 
one means. 

"There can be no manner of doubt," says 
Dr. Philip, before quoted, " that the far-ad- 
vanced or dying cases constitute the greatest 
source of infection." Dr. Newsholme, a 
medical health officer of England, after a 
very thorough and painstaking investigation 
into the disease, and the life and environment 
of the people which influence it, found that 
the diminution of tuberculosis bears a con- 
stant relation to the amount of institutional 
segregation — of isolation in hospitals — that 
the greater the hospital accommodations for 
isolation the greater the diminution of tuber- 
culosis. In England and Wales, Dr. News- 
holme says that a large and continuously in- 
creasing amount of institutional segregation 
has been uniformly accompanied for nearly 
40 years by a large and continuous decrease 
of the disease. None of the other indirect 
means, he says, whether it be less crowding, 
diminution of poverty, increase in wages, bet- 
ter food, shorter hours of labor, etc., though 
they have had an assured influence, has shown 
such uniform variation with the death rate 
from tuberculosis as has isolation. 

London itself, which has for many years 
possessed a number of large hospitals for con- 
175 



TUBERCULOSIS 

sumptives, has a low death rate from the 
disease, 13.46 per 10,000— less than half that 
of Paris, in which latter city, although a large 
proportion of consumptives enter hospitals, 
they remain but a few days, and hence such 
short isolation cannot have much influence in 
reducing the total infection. In New York 
City, where the diminution of tuberculosis has 
been marked and rapid, from 42.7 per 10,000 
in 1881, to 16.6 in 1912, every case of ad- 
vanced disease has an opportunity of being 
treated and isolated in a hospital on an aver- 
age of twenty-one weeks and liberal provision 
has been made by the city for this purpose. 

Disinfection 

Another direct preventive measure is the 
disinfection and renovation of the premises 
which have been occupied by a tuberculous 
individual. Since tuberculosis is now classed 
with the other infectious or contagious dis- 
eases in most communities, the law requiring 
disinfection for such diseases applies to tuber- 
culosis. 

Infected rooms or tenements have been 
found to be instrumental in conveying the dis- 
ease to new and unsuspecting tenants. In 
the " Lung Block " in New York City, 265 

176 



ITS PREVENTION 

cases of tuberculosis were reported to the 
board of health in nine years, and undoubt- 
edly some of these were caused by the infec- 
tion in the rooms from consumptives who had 
previously occupied them. Cornet and other 
investigators have proved that the dust in the 
rooms which were occupied by unclean con- 
sumptives contained the tubercle bacilli. Of 
311 animals inoculated with dust from rooms 
occupied by consumptive patients, Cornet 
found that 167 died soon after infection, 59 
were tuberculous, and 85 were healthy. A 
room in a hotel occupied by a consumptive 
actress, and a workshop occupied by a tailor 
who had directly communicated the disease to 
a fellow-workman, were found infected. But 
in no case was the dust of the walls infectious 
when sputum cups were used exclusively to 
receive the expectorated matter. 

Dr. Ransome cites an instance from Laen- 
nec's writing of a religious community of 
women kept in strict seclusion and with 
somber surroundings, in which Laennec had 
seen consumption arise so frequently that in 
ten years' time the population of the institu- 
tion had been two or three times renewed 
owing to the mortality of the inmates, — with 
the significant exception of those who had 
177 



TUBERCULOSIS 

charge of the gardens, the kitchen and the 
infirmary. Undoubtedly much of this mor- 
tality from tuberculosis was caused by infected 
rooms, for in those days the infectious nature 
of tuberculosis was unknown. 

We see, then, how important it is, from the 
standpoint of prevention, to thoroughly clean 
all offices, workshops, school rooms, etc., and 
in dusting to use moist 'cloths and wet brooms, 
or, better, the modern method of vacuum re- 
moval of the dust. In factories and work- 
shops the cleaning and dusting should be done 
after the day's work, so that there should be 
no dust in the air when the occupants re- 
assemble the next day. 

Compulsory Notification and Disinfection 
No New Thing 

Compulsory notification and disinfection for 
tuberculosis is no new thing, for a hundred 
years or more ago the King of Naples issued 
the following remarkable decree, almost pro- 
phetic in view of what we know and do to- 
day : " Every physician," runs the edict, " is 
henceforth required to report to the author- 
ities every case of consumption the instant 
it is recognized. Failing this a fine of 400 
ducats will be exacted, and for a second of- 

178 



ITS PREVENTION 

fense banishment for ten years. Poor pa* 
tients should at once he taken to the hospital. 
Their clothing and linen shall be kept and 
cared for apart from other patients. In case 
of death every article must be produced and 
identified by the hospital superintendent. Any 
infringement of this law may be punished by 
imprisonment or the galleys. It is the duty 
of those in authority to renovate the room of 
a former patient, floor, hangings and furni- 
ture coverings; to burn the window frames 
and doors and replace them by new ones. 
The extreme penalty of the law will be vis- 
ited on anyone buying or selling the effects 
of phthisical (consumptive) patients. Every 
house where a consumptive dies shall be black- 
listed." In Florence similar laws were en- 
acted. 

In New York City no tenement is permitted 
to be occupied again after the death of a 
consumptive until disinfection has been done 
to the satisfaction of the board of health, 
which performs this office free. This is also 
required in some health resorts and should be 
in all. 

The fundamental idea in disinfection is 
really cleanliness, " surgical cleanliness,'' as 
one might call it. Indeed, if absolute cleanli- 
179 



TUBERCULOSIS 

ness were always maintained in the sick room 
of the consumptive, there would be no need 
of disinfection, as the experiments of Cornet, 
above cited, have shown, for in rooms where 
the sputum was properly disposed of, no tu- 
bercle bacilli were found in the dust. But 
as we can never be sure of this ideal clean- 
liness, we must safeguard the after-comers 
by disinfection. 

Methods of Disinfection 

There are various methods of disinfection 
in use. The one perhaps most generally 
adopted is a thorough fumigation with formal- 
dehyde gas, the room being, as far as possi- 
ble, hermetically sealed by putting strips of 
paper and cotton over the window and door 
cracks or wherever the gas can escape. In 
addition the painted wood work is scrubbed 
with a solution of hot soda, and the walls are 
repainted and repapered after being thoroughly 
cleansed. All hangings, bedding, mattresses, 
pillows and rugs are disinfected with steam, 
or exposed to the air and sunlight for several 
days, and all articles of little value are 
burned. The mere fumigation of the room 
is not sufficient. Renovation is also neces- 
180 



ITS PREVENTION 

sary, — indeed, renovation in conjunction with 
scrubbing and washing the room is probably 
more important and efficient than mere fumi- 
gation. Either before or after the disinfec- 
tion the exposure of the room, by means of 
wide open windows, to the fresh air and sun- 
light for several days, is a useful precaution. 

The whole essence of direct prevention is, 
in a word, cleanliness, which, applied to the 
consumptive, means the proper and safe dis- 
posal of the sputum, whether expectorated 
or coughed out, for " no spit, no consump- 
tion," and a clean consumptive is a safe one 
at home or abroad. So long, however, as 
the unclean consumptive is, unfortunately, al- 
ways to be found somewhere, we must either 
teach him to be clean, clean up after him, or 
isolate him in a hospital; for, in his efforts 
to cure himself, he has no right to jeopardize 
the well community. 

The danger from the unclean consumptive 
is all the greater from the fact that the infec- 
tion is so slow and insidious in its action. An 
individual may become infected and experi- 
ence no immediate results from it; the infec- 
tion may lie dormant in him for years, and 
then on a favorable occasion become active. 
181 



TUBERCULOSIS 

One seldom obtains a history of any known 
exposure to infection from some other con- 
sumptive; yet it must have sometime in the 
past occurred and been forgotten. 

The Indirect Means of Prevention 

The indirect attack in the warfare of pre- 
vention is directed against the human soil, and 
consists in efforts to render it unfavorable 
for the growth of the tubercle bacillus. We 
have already seen what influences tend 
towards the production of a favorable soil, 
and, consequently, the problem in this in- 
direct attack is to combat and correct these 
vicious conditions. 

" Before any vice," says Dr. Holmes, " can 
fasten on a man, body, mind, or moral nature 
must be debilitated." It is the debilitated 
body which offers the favorable soil for tu- 
berculosis, and, therefore, the influences which 
produce this condition must be removed and 
the body raised to and maintained at a re- 
sistant level. All the numberless instrumen- 
talities for improving the public health, famil- 
iar to us all, are effective weapons in this 
warfare; indeed, before the discovery of the 
cause of tuberculosis, imoroved sanitary and 
182 



ITS PREVENTION 

hygienic conditions were already decreasing 
the mortality and prevalence of tuberculosis, 
and they are still most influential, in conjunc- 
tion with the direct means of control, in the 
further diminution of the disease. 

Tuberculosis a Social Disease 

Tuberculosis, as we have said, is often 
called a " social " disease, because the social 
conditions, the conditions of living and work- 
ing, are so influential in its production, and 
in its prevention. In the struggle to improve 
the social condition of the masses, we must 
strive for better homes for the working peo- 
ple, less crowding, shorter hours of work in 
many employments, and better wages; better 
sanitary conditions and ventilation in work- 
shop and factory; more thorough school in- 
spection and care of weakly children ; open- 
air schools and open-air school rooms; the 
prohibition of child labor, and the limitation 
of hours of work for women in factories and 
shops, — protection of mothers; opportunities 
for out-door life by play grounds and parks; 
provision for wholesome recreation and 
amusement; pure and sufficient food, clean 
milk; public baths; better environments for 
child life ; care of the teeth of children through 

183 



TUBERCULOSIS 

free dental clinics; instruction in hygiene; 
fewer saloons, and morally clean cities and 
towns. In every department of social effort 
and uplift the worker is indirectly but 
none the less surely and effectively combating 
tuberculosis. " All social activities," says Dr. 
Routzahn, " touch this problem of tubercu- 
losis, and we can make its consideration a 
medium to agitate for social betterment. Its 
final solution depends on the solution of all 
the complex social, political and economic 
problems of the day." 

Someone has called the tuberculosis war- 
fare one of " enlightened selfishness " because 
the motive of self-preservation is a powerful 
impelling factor in it. Although the disease 
is far more prevalent among the poor than 
the rich, for the latter live under favorable 
hygienic conditions, still the tubercle bacillus 
is an ubiquitous germ, and the possibility of 
contracting the disease is never absent from 
anybody. A consumptive servant, for exam- 
ple, may infect a member of the household 
where she serves; or a tuberculous nurse girl 
the child she cares for: hence all are selfishly 
and personally interested in taking a hand in 
184 



ITS PREVENTION 

the great warfare and working in some of the 
many ways of control and prevention, direct 
or indirect. What a profound sigh of relief 
the world will emit when finally tuberculosis, 
as has happened with most of the other great 
infectious diseases, as we have seen, shall 
have practically disappeared! and it is within 
the power of man to do it, for it is a prevent- 
able disease. 

Three of the most vital points of attack 
in the indirect means of prevention are over- 
crowding, alcoholism, and impure in-door air, 
all of which have been discussed in the chap- 
ter upon the " Seed and the Soil." We have 
seen that overcrowding means dirt, vitiated 
air and greater opportunities for infection, 
and in the illustration of living conditions 
in Paris and London we have seen that tuber- 
culosis increased with overcrowding. 

Better Tenement Houses 

The healthy housing of the poor in model 
tenements in the city, or cheap and rapid 
transportation to the suburbs and the pro- 
vision of proper homes there, must be accom- 
plished if we are to succeed in the struggle. 

185 



TUBERCULOSIS 

Recently both the municipalities and philan- 
thropists have recognized the pressing im- 
portance of the housing problem in the city, 
and much has been done in the way of more 
stringent laws for tenement house building 
and inspection, and in the erection of whole- 
some, well-ventilated tenements. In the writ- 
er's opinion, the final solution of the housing 
problem will be cheap, rapid transportation to 
land in the suburbs. 

Prohibition of Liquor 

We have also seen that among intemperate 
persons an excessive death rate from tuber- 
culosis prevails. Dr. Bertillon, the eminent 
French statistician, has shown that tubercu- 
losis is twice as prevalent among the retail 
liquor dealers of France as among other shop- 
keepers. In the prevention of tuberculosis, 
therefore, the saloon must be controlled, or 
eliminated. If for no other reason than the 
prevention of tuberculosis, State prohibition 
would be amply justified; and one can only 
regard with profound satisfaction, from a 
tuberculosis standpoint, State prohibition and 
no license in the cities. But behind prohibi- 
tion must come better living conditions, nutri- 
tious food, fresh air, and innocent amuse- 
186 



ITS PREVENTION 

fnents, to take the place of the saloon and 
alcohol. 

Pure Air 

It is a self-evident proposition that the con- 
tinued breathing of impure air lowers one's 
vitality; and, consequently, good ventilation, 
letting in the fresh air to our houses, offices, 
schools, public buildings, workshops and pub- 
lic vehicles, is a measure of the first impor- 
tance in the indirect prevention of tubercu- 
losis. Nowhere, perhaps, is such impure, foul 
air met with as in the city street cars in win- 
ter, though some of our churches are equally 
as grave sinners in this respect. The public 
are largely at fault for this condition: they 
are afraid of fresh air ; they want to be com- 
fortable, and when the choice lies between 
impure air and warmth, which makes them 
comfortable, and ventilation, which may mean 
a little colder air and which at first is a little 
less comfortable, they will, or the average 
person will, choose the former alternative. 

It is so often erroneously believed that cold 
air and draughts produce colds. Pure air, as 
we have seen, never does this, for colds are 
caught from some one else suffering from 
them, or from the infection scattered about 
by them. Nansen, the Arctic explorer, en- 
dured all sorts of exposure to cold and wet 

187 



TUBERCULOSIS 

on his Arctic expedition, yet, he tells us, he 
never had a cold until he returned to civil- 
ized life and slept in a house. With a little 
training and hardening one can learn to sit 
in his office or eat his dinner with an open 
window and enjoy the stimulation of the cool 
fresh air, even in the midst of winter. 

One of the valuable incidental benefits of 
this great tuberculosis campaign is the em- 
phasis laid upon the importance of fresh air. 
If fresh air will accomplish such marvelous 
results in the treatment of tuberculosis as it 
does, then it must be good for those who are 
well and desire to avoid the disease. The 
gospel of fresh air has never been so inces- 
santly and universally proclaimed as it is to- 
day in connection with the prevention and 
cure of tuberculosis. Once one becomes ac- 
customed to an abundance of fresh air, he 
will crave it almost as the drunkard does his 
dram, and he will never again, if he can avoid 
it, subject himself to the misery of impure 
air. 

What has been said above regarding the 

prevention of tuberculosis applies, of course, 

to the individual as well as to the public at 

large ; but there are certain precautions which 

188 



ITS PREVENTION 

have a mora direct personal application and 
which it will be well to mention. 



Important Points to Remember 

In the first place, if one has a " poor con- 
stitution," as we say, and is not strong and 
robust, an out-door occupation is preferable 
to confinement in-doors; but if he is unable 
to do this, he should take especial measures 
to strengthen his body, by exercise out-of- 
doors, winter and summer, deep breathing-, 
plain and wholesome food, well prepared, well 
chewed and taken at regular times, and by 
sufficient rest and sleep with an abundance 
of fresh air in the bedroom, — and, in brief, 
an observance of all the laws of health and 
avoidance of all excesses. 

The average person should sleep at least 
eight hours, alone, in a well-ventilated room, 
and should breathe through the nose wifh the 
mouth shut. 

If a cold bath is good for a tuberculous 
individual, it is equally so for a well person, 
and one should form the habit of taking it 
every morning. The teeth should be brushed 
at least after breakfast and at night on retir- 
189 



TUBERCULOSIS 

ing. The mouth should be frequently rinsed, 
and the hands washed before eating. " Let 
order and cleanliness have the first place in 
the whole conduct of life." 

A cold or cough should not be neglected, 
and if any of the early symptoms of tuber- 
culosis mentioned in Chapter VI are observed, 
one should immediately consult a physician. 
If it can be avoided, one should not sleep in 
a room with a consumptive, and if he is 
obliged to live in a house with one, or work 
in an office or shop near one, he should see 
that he properly disposes of his sputum and 
holds something before his mouth when 
coughing. One should not put the fingers 
in the mouth or nose, or any unclean thing, 
such as money, the point of a lead pencil, 
half-eaten apples, chewing gum, candy, etc., 
which others have handled. In turning the 
leaves of books or handling money or papers, 
the finger or thumb should not be moistened 
with saliva. Drinking from a cup or glass 
used by another should be avoided, unless the 
vessel has been first thoroughly cleaned. 
Kissing may carry infection, and one should 
not kiss a consumptive. In desk work in 
school or office, avoid a bent position, — let 
the lungs have full play. 
190 



ITS PREVENTION 

A Clean House and Dust 

Live in a clean house accessible to the en- 
trance of air and light, preferably in the 
suburbs. Twice a year the house should be 
thoroughly cleaned. In dusting use a moist 
cloth or, when possible, remove the dust by 
the vacuum system. Dust is dirt in tiny un- 
seen particles in the air, and contains among 
other things various kinds of germs, some 
of which may be infectious. Dust is always 
a possible danger, and should be scrupulously 
avoided, as well as disorder, dampness, dark- 
ness and bad air. Plain, durable clothing 
should be worn, just thick enough to keep 
one comfortable, and if the clothing or shoes 
become wet, they should be immediately 
changed. In moving into a house in which a 
tuberculous person has recently lived, one 
must be sure that it has first been properly 
disinfected. This is of great importance in 
occupying a cottage in a health resort. 

Spitting and Cuspidors 

Of course everyone should avoid indiscrim- 
inate spitting himself and shun all places 
where it is permitted, and, further, he should 
try in every way to persuade others from in- 
dulging in the habit. It is an evident hard- 
191 



TUBERCULOSIS 

ship, however, to prohibit all spitting, and 
when in the right place it is often a cleanly 
thing to do, as when one has a cold in the 
head, or, from other causes, has some un- 
cleanly discharge in his mouth; but it should 
be done in the right place, in spittoons pro- 
vided for the purpose, partially filled with 
water, and which are cleansed at short inter- 
vals, preferably by boiling. By a law of 
Massachusetts, suitable receptacles for expec- 
toration are required in all factories and work- 
shops, the form and number of which to be 
decided by the board of health of the city or 
town in which the factory is situated. 

We cannot yet destroy all the tubercle 
bacilli, but we can so strengthen and harden 
the body that it will be difficult for the germs, 
even if they do get in, to do harm. 

" The struggle against tuberculosis," says 
M. Casimir Perier, " is intimately bound up 
with the solution of the most complex eco- 
nomic problems, and any plan will be imper- 
fect which has not for its foundation the ma- 
terial and moral improvement of the people." 



192 



XL THE GREAT CRUSADE AGAINST 
TUBERCULOSIS 

CHERE are two profoundly im- 
pressive movements taking place 
in the world to-day, both of 
which, although in a very differ- 
ent way, have for their ultimate 
object the preservation of human life. The 
one is the great Peace movement, whose object 
is the abolition of war between nations and 
the settling of their disputes by arbitration; 
the other is the present world-wide Crusade 
against tuberculosis. Of the extent and 
earnestness of this latter movement, the re- 
cent great International Congress of Tuber- 
culosis in Washington (1908) is a witness. 

Organized Effort Almost Universal 

In almost every civilized country of the 
world organized effort is now being made for 
the purpose of fighting tuberculosis. While 
the general methods are and must be the same, 
each nation modifies them according to its 
193 



TUBERCULOSIS 

own peculiar conditions, and its conception 
of what are the most important lines of at- 
tack. 

International Congresses 

At certain intervals representatives of all 
the nations come together in a great interna- 
tional congress such as the one just referred 
to in Washington, where they compare the 
methods and results of the work in their re- 
spective countries, learn new facts regarding 
tuberculosis and new ways of fighting it, and 
inspire one another to increased effort. The 
last such congress was held in Rome in 1912 
and the next one will be in London. 

The Movement Simultaneous Among All 
Peoples 

Such national and international action 
against tuberculosis is called the " Crusade," 
the " Warfare," and " Struggle " against 
tuberculosis. All classes of people, from 
the king to his humblest subject, and 
from the president to the laborer, are en- 
gaged in this Crusade. It is a fact of strik- 
ing significance that the peoples of the 
world should thus simultaneously set them- 
selves to work to free themselves from this 
194 



ITS PREVENTION 

inveterate foe which for untold years has 
been preying upon the flower of their youth 
and manhood. The inspiration of this Cru- 
sade arose from Prof. Koch's great discov- 
ery of the cause of tuberculosis. Then and 
not until then could intelligent action be taken. 
The Crusade began at first slowly, but as time 
went on and the possibility of the prevention 
and cure of the disease became more fully 
realized, the movement began to grow in ex- 
tent and force until at present, as we have 
said, it has become world-wide. 

Why a Crusade Against a Single Disease? 

Perhaps one may ask why such a crusade 
against a single disease? Other diseases are 
very prevalent, such as heart, or kidney dis- 
ease, rheumatism, and, more frequent than 
all, as we have seen, pneumonia. There are 
several reasons for this. In the first place, 
there is no other disease which so habitually 
cuts down its victims in the best years of 
their life. Many diseases only occur in later 
life, and are called degenerative diseases, 
caused by worn-out organs. Pneumonia, as 
has already been said, is most prevalent and 
fatal at the two extremes of life, — before 
one's work is begun and when it is done. 
195 



TUBERCULOSIS 

Again, tuberculosis is a contagious or com- 
municable disease, the cause of which we 
know, as well as its prevention. We know 
how to avoid it, to prevent it, to cure it. 
Finally, it has a steady, continuous preva- 
lence without intermission. Many contagious 
diseases come in epidemics and then cease; 
tuberculosis never ceases. 

Principal Forms of Activity 

The principal forms of activity in the cam- 
paign against tuberculosis consist in: 
(i) Educational propaganda. 

(2) Sanatoria. 

(3) Tuberculosis dispensaries. 

(4) Tuberculosis hospitals for advanced 
cases. 

(5) Laws and regulations regarding noti- 
fication, disinfection, indiscriminate expectora- 
tion, isolation of advanced cases. 

(6) The founding of tuberculosis associa- 
tions and leagues. 

(7) The prevention of tuberculosis in chil- 
dren and care of tuberculosis children. 

(8) General improvement of the hygienic 
and living conditions of the poor in cities by 
improved dwellings, etc. 

196 



THE GREAT CRUSADE 

(9) Inspection of factories and workshops 
and improvement of sanitary conditions of 
the same. 

(10) Supervision of the milk supply. 
Germany 

Germany took the lead in this warfare, and 
it was quite natural that it should do so, for 
Prof. Koch, who made it possible, was him- 
self a German. The lines of effort in Ger- 
many are various and include both the direct 
and indirect attack. Their main effort is, 
perhaps, in the line of the direct attack, the 
cure of the curable cases, and the protection 
of the well, particularly the latter. No coun- 
try possesses so many sanatoria, both pub- 
lic and private, as does Germany. There are 
considerably over 100 such institutions with 
10,000 or more beds, and about 40,000 in- 
dividuals are treated every year in them. 
Some have been established, and they are 
among the best and largest, by the National 
Insurance Societies, who insure all workmen 
against disease. Others have been erected 
by cities, communities, the Red Cross Society, 
corporations and private individuals. About 
65 per cent, of the patients treated in these 
sanatoria become fully caoable of resuming 
197 



TUBERCULOSIS 

their former work, an "economic cure," as 
it is called. To treat its consumptive work- 
ingmen in sanatoria in the early stage of their 
disease, and discharge them in a condition 
to resume their work, was found to be far 
more economical than to care for them through 
a lingering illness. 

Compulsory Insurance of Workingmen 

One of the most admirable institutions in 
Germany, which has done more than all other 
means in this struggle against tuberculosis, 
is the compulsory insurance of workingmen. 
Every workingman (one- fourth of the popu- 
lation of Germany) is compelled by imperial 
law to be insured against sickness, accident 
and invalidity. Each insurance company se- 
cures for the laboring man, in case he is per- 
manently disabled by sickness or accident, 
an allowance for life. For this purpose the 
employer as well as the employee are re- 
quired to contribute their share in equal parts : 
the highest amount the latter — the working- 
man — contributes is six cents a week. The 
most important thing for the workingman as 
well as for the insurance company is to be 
able to work and to maintain this working 
198 



THE GREAT CRUSADE 

ability as long as possible. Hence one of the 
principal objects of the insurance companies 
is to prolong the working period. Just as 
soon, therefore, as tuberculosis is discovered 
in a workingman, he is at once placed under 
treatment in one of the well-equipped sana- 
toria constructed by the insurance companies, 
where he is treated free of cost for an in- 
definite period. During the time that he is 
under treatment his wife and children are 
supported in every way by the company. The 
same companies also maintain dispensaries 
and day camps for the workingman and pro- 
vide him with dental attention free of cost. 
All this is done, not out of philanthropy, but 
from a purely economic basis. The insur- 
ance companies have found it cheaper, as we 
have said, to treat and cure the tuberculous 
workingman and get him back to work and 
off their hands than to support him and his 
family during a much longer period of illness, 
if the disease is allowed to run on without 
timely treatment. How difficult it is to make 
communities realize this proved economic fact ! 
They allow the poor consumptive to run on 
into a hopeless condition, and then they have 
to take care of him at public expense as long 
199 



TUBERCULOSIS 

as he lives, and at the same time care for his 
family. How much cheaper it would be to 
treat the consumptive at the right time, and 
in the right place, until he was well. 

These German insurance companies for 
working people have at present a capital of 
five hundred millions of dollars, and in 1907 
the German Workingman's Insurance Com- 
pany had expended for the tuberculosis cam- 
paign $3,000,000. A further extension of 
this compulsory insurance is already deter- 
mined upon, namely, the care of widows and 
orphans of workingmen. 

There are some things that an enlightened 
monarchical form of government can do for 
its subjects better than the people in a demo- 
cratic form of government can or will do for 
themselves, and, evidently, the compulsory 
insurance for workingmen would seem to be 
one. 
Information Bureaus 

In Berlin there have been established " In- 
formation Bureaus," as they are called, whose 
purpose it is to prevent the spread of pul- 
monary tuberculosis. At these bureaus, any 
one who desires it can have his lungs exam- 
200 



THE GREAT CRUSADE 

hied free of charge, and if tuberculosis is 
discovered, he is instructed as to the neces- 
sary measures to be taken to prevent the in- 
fection of others, and is cared for as his cir- 
cumstances require. All the members of his 
family are required to present themselves for 
examination. The patient's home and family 
are kept under constant supervision, and 
proper sanitation is secured and the inmates 
trained to live hygienically. The striking fea- 
ture of these bureaus is the constant watch 
maintained over the home and family of the 
consumptive, to prevent the spread of the 
disease from the sick member to others of 
his family. 

Other Forms of Tuberculosis Work in Germany 

The Germans have also developed many 
other forms of tuberculosis work, such as 
the park convalescent or day camps; forest 
schools for tuberculous children in the vi- 
cinity of large cities; vacation settlements; 
farm colonies for patients discharged from 
the sanatorium ; sea-side hospitals for children 
with bone, joint or gland tuberculosis. In 
Berlin and elsewhere model, clean, well-vem 
201 



TUBERCULOSIS 

tilated tenements have been erected in in- 
creasing numbers, and for this purpose large 
sums have been loaned by the state and the 
workingmen's insurance institutions. Besides 
the above special kinds of effort, there are 
also the various measures common to other 
countries, such as restriction of spitting, dis- 
infection, compulsory notification, etc. It. is 
said that Berlin has the best control of the 
tuberculosis situation of any city in Europe 
comparable to Boston and New York City in 
this country. 
England 

England comes next to Germany of Euro- 
pean countries in its activity in the tubercu- 
losis Crusade. Long before Koch's discov- 
ery, consumptive hospitals existed in London. 
The largest of them, the Brompton Hospital, 
was established in 1841, and its foundation 
happened in an interesting way: A consump- 
tive clerk of Sir Philip Rose was rejected at 
several general hospitals, and learning of the 
fact, certain philanthropists determined to 
erect a special consumptive hospital; and the 
result was the great Brompton Hospital with 
between three hundred and four hundred beds. 
It is doubtless partly due at least to its con- 
sumptive hospitals that the death rate from 
202 



THE GREAT CRUSADE 

this disease is so low in London, one of the 
lowest in any large city, less than half that 
in Paris and Vienna. 

There are also many sanatoria in England. 
One of the newest is the King Edward VII 
Sanatorium, costing $1,000,000, the gift of 
one man. There is a national association for 
the prevention of tuberculosis and many simi- 
lar local associations. In 1901 a great In- 
ternational Congress on Tuberculosis was held 
in London. In Edinburgh Dr. Philip estab- 
lished the well-known Victoria Dispensary in 
1 887, one of the first and best of the kind in 
the world. In some English towns consump- 
tives are received for temporary residence in 
isolation hospitals for educational purposes, in 
order that they may learn how best to live 
wholesome lives and how to deal with their 
sputum. The city of Birmingham was the 
first city to erect a municipal sanatorium for 
its consumptive sick; and it is interesting to 
recall the fact that near this city, sixty years 
ago, George Bodington erected his sanatorium 
for the open-air treatment of tuberculosis and 
received such opposition that he was obliged 
to abandon the scheme. The new sanatorium 
surely ought to be dedicated to his memory. 

England is also doing much in an indirect 
way in the prevention of tuberculosis by its 
203 



TUBERCULOSIS 

excellent sanitary service, model tenements,' 
better and cheaper food, decrease of alcohol- 
ism, and a general diminution of pauperism, 
all of which has played an important part in 
the steady decline of the death rate from 
tuberculosis which has been going on in Eng- 
land for many years. The English govern- 
ment has now established the " National 
Insurance Act " similar to the German " Com- 
pulsory Insurance law," and provided a capi- 
tal sum of $7,500,000 for the erection of 
sanatoria for the entire community. 

Ireland 

In 1907 the Women's National Health As- 
sociation of Ireland, under the leadership of 
the Countess of Aberdeen, inaugurated an 
aggressive campaign against tuberculosis, 
which is far more prevalent in that country 
than in England. If the death rate from tu- 
berculosis in Ireland was reduced to that in 
England, it would mean the annual saving 
of 4,000 lives in the former country. By 
means of a traveling tuberculosis exhibition, 
accompanied by lectures upon the subject, 
public enthusiasm was aroused throughout the 
land. " Everywhere," says the report upon 
the movement, " the talk is of tuberculosis, 
fresh air, open windows; and the virtues of 
204 



THE GREAT CRUSADE 

the same are being discussed with vehemence 
in the clubs and public houses." In one place 
visited by the exhibition and the Countess, a 
number of people in the poor streets decided 
to show their welcome of the Countess by 
whitewashing their houses inside and out. 
" The bishops and clergy of all denomina- 
tions, the landlords and tenants, the town and 
city officials, the town's people and the peas- 
ants, were all united in the desire to stamp 
out tuberculosis. In 1908 the Tuberculosis 
Prevention Act was passed, which gives 
power to county councils to establish sana- 
toria and dispensaries. In 1912 there were 
17,000 fewer people suffering from tuber- 
culosis in Ireland than there were in 
1907. 

France 

In France, where there is a high mortality 
from tuberculosis there are comparatively few 
sanatoria for adults, but the main effort is 
directed to the prevention and treatment of 
tuberculosis in children. The authorities in 
this country consider that the infection gen- 
erally takes place in childhood, and, therefore, 
the chief attention should be directed to pre- 
venting tuberculosis in the child, when it is 
exposed to the contagion in the home where 
205 



TUBERCULOSIS 

some member is suffering from the disease. 
There are probably more sanatoria for chil- 
dren in France than in all the other countries 
combined, and some of the largest and most 
famous sea-side sanatoria for children are 
situated in this country ; and in all of them — 
twenty- four in number, — there are accommo- 
dations for about 4,000 children. 

Further consideration of this work of the 
French with tuberculous children will be 
given in the chapter upon " Tuberculosis and 
the Child." 

The system of dispensaries is very exten- 
sive in France, and at Lille Dr. Calmette 
established one of the first model dispensaries 
in Europe, which he called a " Preventorium," 
and which has become famous throughout the 
world. There are many anti-tuberculosis 
leagues throughout France, united in a na- 
tional federation under the patronage of the 
president of the republic. In 1905 an Inter- 
national Tuberculosis Congress was held in 
Paris, under the auspices of the government. 
Instruction is also given in the schools re- 
garding tuberculosis. 

Sweden 

In Sweden, which has a yearly mortality of 
about 10,000, there is a national tuberculosis 
206 



THE GREAT CRUSADE 

association, which carries on an educational 
propaganda by lectures, publications and a 
tuberculosis museum at Stockholm. It is in- 
teresting to learn that the chief source of in- 
come of this association is through the pop- 
ular method of selling charity stamps, similar 
to the Red Cross stamps ; and during the 
years 1905 to 1907 the amount obtained in 
this way was about $60,000. 

Sanatoria have been established both by the 
general and local governments; and the for- 
mer has appropriated $3,000,000 and land for 
the next ten years for this purpose. In 1895, 
at the Twenty-fifth Jubilee of the reign of 
King Oscar II, the national collection made 
to commemorate the event, amounting to over 
half a million dollars, was donated by him for 
the erection of public sanatoria, and this sum, 
together with a quarter million more voted 
by Parliament, was applied to the erection 
and maintenance of sanatoria in different 
parts of the kingdom. Dispensaries have also 
been established where milk and other food 
are distributed to needy consumptives. 

An interesting experiment has been inaug- 
urated in this country of establishing a house 
with a number of tenements, hygienically 
clean and wholesome, for families in which 
the father or mother, or both, were suffering 
207 



TUBERCULOSIS 

from tuberculosis but still able to work, the 
children being healthy. Such a house has a 
resident nurse, who pays a daily visit to every 
family and instructs them as to cleaning, ven- 
tilation, the proper care of the sputum, etc. 
Everything, though very simple, is kept hy- 
gienically clean. A somewhat similar experi- 
ment is now being carried out in the Vander- 
bilt East River Homes in New York City. A 
very important work is also being done with 
healthy children of consumptive parents. 
With the consent of the latter, the children 
are removed from their homes and the chances 
of infection, and boarded out in temporary 
homes or institutions. The public press of 
Sweden has also been very helpful in the tu- 
berculosis Crusade. 

Denmark 

In the little country of Denmark, with a 
population of a little over two and a half mil- 
lions, there is a national association which 
maintains five sanatoria for the poor, and a 
dispensary at Copenhagen. This association 
is also very active in the educational propa- 
ganda, disseminating literature and provid- 
ing lectures for the public and for school 
children. It was also aided in the erection 
of other sanatoria in out-of-the-way islands, 
208 




THE VANDERBILT EAST RIVER HOMES. 



THE GREAT CRUSADE 

as in the Faroe Islands, where there is a com- 
bined hospital and sanatorium. 

The state and various societies maintain 
other sanatoria, consumptive hospitals, and 
sea-side hospitals and sanatoria for children, 
affording, in all, accommodations for 2,180 
patients of the poorer classes, so that anyone 
who desires can obtain admission in some of 
these institutions. Among the public meas- 
ures for combating tuberculosis are compul- 
sory notification, compulsory disinfection af- 
ter death from tuberculosis, prohibition of 
spitting, and the prohibiting of women suf- 
fering from tuberculosis from becoming wet 
nurses. Tuberculous children are prohibited 
from attending school and tuberculous teach- 
ers from teaching school. Before children be- 
gin to work in workshops or factories, a doc- 
tor's certificate must be produced, stating that 
they do not suffer from tuberculosis. Chil- 
dren living under such conditions in their 
homes as are injurious to their health, may 
be taken away from the parents and boarded 
out in good homes. No person suffering 
from tuberculosis of the lungs and throat is 
allowed to fill an office in the civil service that 
would bring him in close contact with the 
people. Another excellent provision requires 
that the floor of school rooms shall be washed 
209 



TUBERCULOSIS 

at least twice a month, and that the floor as 
well as the desks, etc., shall be wiped with a 
wet cloth every day after school hours while 
the premises are being aired. 

Switzerland 

In Switzerland whose yearly mortality from 
tuberculosis is 9,000, there are many so-called 
high-altitude resorts for tuberculosis which are 
visited by consumptives from various portions 
of Europe. Davos is best known and contains 
several sanatoria. Leysin, St. Moritz, Ander- 
matt and Arosa are of similar climatic char- 
acteristics. There are a number of popular 
and private sanatoria with accommodation in 
all for 1,600 patients, and, in addition, several 
institutions for tuberculous children, and what 
are called holiday colonies for children and 
farm colonies for convalescent adults. As 
with the other countries, there are many tuber- 
culosis associations in Switzerland, and in the 
canton of Bern the Grand Council has adopted 
extensive provision for the educational propa- 
ganda and the prevention of tuberculosis. Al- 
coholism is given as the most common pre- 
disposing cause of the disease in this country. 
It seems strange that a land like Switzer- 
land, with such pure mountain air, should suf- 
210 



THE GREAT CRUSADE 

fer very much from tuberculosis, but here 
again the in-door life, fostered by the long, 
cold winter, is probably a powerful contribu- 
ting cause, together with alcoholism, just men- 
tioned. 

Belgium 

Belgium has a large and active National 
League against tuberculosis with over 6,000 
members. It has established dispensaries, 
cares for consumptives, and expends in this 
work more than $50,000 annually. The dis- 
pensary system is elaborately developed in 
Belgium, after the plan of Calmette in France, 
and the name " Preventorium," which he 
originated, is applied to them. Sanatoria 
have also been established, the one in the 
province of Liege costing $240,000. The 
campaign against tuberculosis in the Belgian 
army has been vigorously pushed and strict 
measures have been adopted with regard to 
it. In the rooms of all military establish- 
ments are placards with the following in- 
scriptions : " Do not spit on the floor : it is 
dirty and dangerous, as the tuberculous 
sputum, dried and reduced to dust, is the 
means of spreading consumption." Large 
211 



TUBERCULOSIS 

sums of money have been spent in the build- 
ing and improvement of barracks, schools and 
hospitals. 

Norway 

Norway was the first country to pass laws 
requiring compulsory notification of tubercu- 
losis, disinfection after death, or change of 
residence, and removal to a hospital if hy- 
gienic instruction were not carried out. So- 
called Nursing Homes were first established 
in this country, primarily for the purpose of 
isolating advanced and incurable cases. These 
homes, containing six to ten beds, are in 
charge of a nurse, and are plainly but com- 
fortably constructed, and maintained at a 
small cost. As it is well known, leprosy has 
existed in Norway for centuries, but is now 
nearly extinct, owing to its being isolated. 
Funds devoted to this purpose ever since the 
Middle Ages have now been diverted to the 
care of tuberculous persons, and a leper hos- 
pital, no longer needed for its original purpose, 
has been changed to a sanatorium. May this 
same thing happen with regard to tubercu- 
losis, and when that becomes extinct, the sana- 
toria converted to other uses. There are a 
212 



THE GREAT CRUSADE 

number of private sanatoria in Norway, and 
two marine ones for the treatment of surgi- 
cal tuberculosis in children. 

In the city of Bergen, where the Crusade 
has been energetically carried on, the mortality 
from tuberculosis has decreased about 50 per 
cent, within the last eleven years. It is a 
notable fact that the decrease is greatest in the 
cities. 

Tuberculosis Work in Other Countries 

In similar ways the great Crusade is in 
progress in Russia, Italy, Spain, Portugal, 
Roumania, Bulgaria, Bohemia, Turkey and 
Greece. Both the governments and the peo- 
ple are united in this great movement. By 
the invitation of the King of Italy the last 
International Tuberculosis Congress was held 
in Rome in 1912. 

On the other side of the globe, Japan, Aus- 
tralia and New Zealand are actively engaged 
in this cause. On this side of the water many 
of the South America states, Mexico and 
Central America, have their anti-tuberculosis 
leagues, and have established dispensaries and 
sanatoria. Indeed, at the present time one 
could almost estimate the degree of civiliza- 
213 



TUBERCULOSIS 

tion of any country by the degree of its ac- 
tivity in the great Crusade against tubercu- 
losis. 

Canada and Brehmer Rest 

In Canada, besides its tuberculosis associa- 
tion with its various affiliations and its pub- 
lic and private sanatoria, there is a most 
valuable and interesting institution at St. 
Agathe-des-Monts, in the Laurentian Moun- 
tains, called " Brehmer Rest," or the "Pre- 
ventorium," where young workingwomen 
who do not have tuberculosis, but seem pre- 
disposed to it, such as convalescents from 
various acute diseases, shop girls, factory 
workers, typewriters, etc., are received and 
by rest, good food, and fresh air, restored 
to their normal health and resisting power 
and thus rescued from the possibility and, 
with many, the probability of developing 
active tuberculosis, thus admirably illustrat- 
ing the fact that the best time to treat a dis- 
ease is before it begins; and in weeks doing 
what later it would take months to accom- 
plish, when active tuberculosis begins. If, 
as has been asserted by a good authority, 
from 50 to 90 per cent, of us all have had 
tuberculosis at some time, or will have 
214 



THE GREAT CRUSADE 

it before we die, though it may never be- 
come active, then the value of such a " Pre- 
ventorium " is evident, for many of its in- 
mates undoubtedly would, if left to go on in 
their depressed vital condition, develop active 
disease. The best means to avoid tuberculosis 
is to always keep one's self in a sound state 
of health, and, consequently, in a state of re- 
sistance to the tubercle bacilli; and when, for 
one reason or another, one's vitality gets low, 
the danger threatens, and this unique institu- 
tion, the " Preventorium," is the helping hand 
which aids in warding it off. 

The Tuberculosis Crusade in the United 
States 

In the United States we find that the ratio 
of tuberculosis per 1,000 of the population is 
about that in England, and yet the campaign 
against the disease in the past has not been 
as active in this country as in the latter. 
Now, however, for several years past the 
country has been awakening, and increased 
effort is being made. The International 
Congress at Washington has undoubtedly 
had its influence in stimulating the states 
and people to greater activity. We have 

215 



TUBERCULOSIS 

as yet, unfortunately, no National Bureau of 
Health, as in Germany, to lead in such great 
movements as this one against tuberculosis. 
Civilization has not yet arrived at that stage 
when the protection of health is regarded as 
paramount to the protection of property. 
Neither does the general government appro- 
priate any considerable sums for the preven- 
tion of disease in man, although it maintains 
a cattle bureau and, presumably, makes a lib- 
eral appropriation for this object. 

The Price of a Battleship for the Tuber- 
culosis Crusade 

If only the price of one battleship could 
each year be devoted to the prevention of 
tuberculosis, how much could be accom- 
plished; and if half of what is now appro- 
priated for military purposes could be em- 
ployed against this one disease, with what 
strides should we see it disappear! Since 
the year 1908 the amount of tuberculosis ac- 
tivity in this country has been steadily increas- 
ing and nearly twenty million dollars have 
been expended in the campaign of 19 13. The 
State of New York appropriated nearly four 
million; Pennsylvania over a million and a 
216 



THE GREAT CRUSADE 

half ; Massachusetts over a million ; and about 
three millions was expended by fraternal or- 
ganizations, labor unions and insurance com- 
panies. Since 1909 the percentage of public 
money spent in tuberculosis work has in- 
creased from 53.5 to nearly 70 per cent. 
What could have been accomplished if $10,- 
000,000, the price of one battleship, had been 
available in addition! It has recently been 
proposed by Dr. Knopf of New York that 
the United States government should place at 
the disposal of the various states of the Union 
some of its discarded battleships and cruisers 
to be used for open-air schools, preventoria, 
and sanatorium schools for children, or hos- 
pital sanatoria for adults. The Italian gov- 
ernment has done this with three of its dis- 
carded men-of-war. 

What the United States Government is 
Doing 

The tuberculosis work in the United States 
has been chiefly carried on by the people, 
through voluntary associations, and by the 
state governments. The United States gov- 
ernment, however, has established sanatoria 
for its soldiers and sailors in Colorado and 
New Mexico, and has also promulgated rules 
217 



TUBERCULOSIS 

and regulations against indiscriminate spitting 
in all government buildings, such as the post 
offices and various government departments 
in Washington. In 1905, President Roose- 
velt issued orders for the purpose of pre- 
venting and eliminating tuberculosis among 
the employees in the public service. The sani- 
tary condition of all public buildings and 
workshops was to be inspected and rules of 
prevention were required to be displayed. 
Any consumptive workman was to take spe- 
cial care not to infect others, and those sus- 
pected of having tuberculosis were to be ex- 
amined at public expense. 

The National Tuberculosis Association 

Nine or ten years ago a National Associa- 
tion for the study and prevention of tuber- 
culosis was founded, the chief function of 
which is educational. In carrying out this 
educational work, the association has sought 
to interest all classes of people to aid cities, 
towns, and states in organizing tuberculosis 
associations, in procuring special legislation 
in the interests of tuberculosis prevention and 
care and in disseminating knowledge regard- 
ing the many means and methods of fighting 
tuberculosis, and in collecting statistics upon 
218 



THE GREAT CRUSADE 

the many phases and movements of the tuber- 
culosis crusade. There are now in this coun- 
try over twelve hundred tuberculosis associa- 
tions. Sanatoria and dispensaries have also 
been rapidly multiplying and there are now 
527 special tuberculosis sanatoria and hos- 
pitals and 395 tuberculosis dispensaries, and 
their number is almost daily increasing. 

The Red Cross Stamps 

By means of the Red Cross stamps or seals, 
40,000,000 of which were sold last Christmas, 
not only has a very considerable amount of 
money been raised for the cause, but they 
have proved one of the greatest mediums of 
education. These stamps are widely adver- 
tised by colored posters and cards placed in 
store windows, stations of the subway and 
elevated roads, and posted about the city. On 
a poster, among other things, was the follow- 
ing in large letters : " Every stamp means a 
bullet in the fight against tuberculosis." The 
stamps were for sale in many of the leading 
department stores, confectionery stores, sta- 
tioners, etc. In Chicago, the post office gave 
the tuberculosis institute a booth which was 
attended by a body of nurses from the hospi- 
tals. The following was written in praise 
of the virtue of the stamp: 
219 



TUBERCULOSIS 

"I'm the Red Cross Christmas Stamp. 

This that I propose is, 
To summon wealth to fight for health 

And beat tuberculosis, — 
Beat the greatest plague of all, 

Oust a pall of sadness, 
Treat despair with food and air 

And lift it into gladness." 

The Clergy and Churches and Societies 

The labor unions have entered into the 
campaign with great zeal and activity, and 
the churches and clergymen all over the 
country are uniting in preaching the great 
Crusade. Churches are forming and main- 
taining tuberculosis classes, and clergymen 
are preaching sermons on tuberculosis. Every 
year a certain Sunday is designated as " Tuber- 
culosis Day." In 1912 over 60,000 churches 
gave attention to this subject on " Tuberculosis 
Day." In the Roman Catholic Church the 
clergy are instructing their congregations 
upon tuberculosis, and the subject is being 
taught in the parochial schools. Thus a mil- 
lion and a quarter school children and seven- 
teen million Catholics in the United States 
are being reached. The Young Men's Chris- 
tian Association, the Christian Endeavor So- 
220 



THE GREAT CRUSADE 

cieties, the women's clubs and many civic 
and social societies are all interested in the 
campaign and are learning and preaching the 
gospel of the prevention of tuberculosis and 
its cure by fresh air, rest, and wholesome 
food. Besides its great educational propa- 
ganda, the National Association is continu- 
ally investigating the various problems con- 
nected with tuberculosis, such as the cost and 
best methods of the construction of sanatoria, 
tuberculosis among children, and many other 
problems. 

Governors and Legislatures 

It is a significant fact to notice the atten- 
tion now devoted in the various states by gov- 
ernors and legislatures to the subject of tuber- 
culosis. In 191 3 out of 41 state legislatures 
in session, laws dealing with tuberculosis were 
enacted in 30 states. In their messages, gov- 
ernors urge upon the legislatures the impor- 
tance of taking some action against tuber- 
culosis. Said the Governor of West Virginia 
in a message to his legislature : " Preven- 
tion will, to an extent, include the care of 
those who are afflicted and who cannot take 
care of themselves, in order to guard against 
the danger of their infecting others. One 
221 



TUBERCULOSIS 

consumptive person may infect hundreds of 
others, for he will grow and emit millions of 
the diseased germs. Hospitals or like places 
where such persons may be isolated and 
treated is a necessary part of any reasonably 
effective campaign against the dreaded dis- 
ease. That it would be a noble charity goes 
without saying. I recommend to the legisla- 
ture the earnest consideration of the pressing 
matter of promoting the public health, espe- 
cially as concerns the safe-guarding of the 
people against the awful ravages of consump- 
tion." " For every dollar we spend in getting 
rid of this scourge" (tuberculosis), said 
Governor Hughes in a recent address, " we 
should save a hundred dollars in increased 
productivity and efficiency." 

New York 

Of the individual states, perhaps New 
York, Massachusetts, Pennsylvania and Wis- 
consin are the leaders in the Crusade, al- 
though many others are closely following 
them. We have already seen what New York 
City has done in compulsory registration, dis- 
infection, and in the provision for its tuber- 
culosis inhabitants in sanatoria, hospitals and 
dispensaries. The first sanatorium in this 
country was established by Dr. Trudeau in 

222 



THE GREAT CRUSADE 

the Adirondacks in New York State, and is a 
monument to his devotion to the cause. At 
Coney Island is a sea-side sanatorium for 
tuberculous children. 

Pennsylvania 

In Pennsylvania a society for the prevention 
of tuberculosis has existed since 1892. In 
Philadelphia is the great Henry Phipps Insti- 
tute recently erected for the study, treatment 
and prevention of tuberculosis, established and 
maintained by a gift of $1,000,000 by the phi- 
lanthropist whose name it bears. Both a hos- 
pital for advanced cases and a dispensary are 
maintained by this institute and much atten- 
tion is devoted to the study of tuberculosis 
in all its phases. 

Delaware is the only state which has made 
provision for a state sanatorium for tubercu- 
lous negroes. 

Massachusetts 

Massachusetts erected the first state sana- 
torium in the country, and it affords accom- 
modations for 350 patients. This same state 
has also established three other sanatoria for 
early and advanced cases of tuberculosis. 
The first day camp in the United States had 
its origin near Boston, and in the same city 
one of the first hospital schools for tubercu- 
223 



TUBERCULOSIS 

lous children was instituted. By an act of the 
legislature, fifteen state inspectors of health 
were appointed who are physicians, and as a 
part of their duties they are required to 
"gather all information possible concerning 
the prevalence of tuberculosis and other dis- 
eases dangerous to the public health in their 
respective districts." Laws have been enacted 
requiring the establishment of local hospitals 
and dispensaries for tuberculosis throughout 
the state. Thus it will be seen that the peo- 
ple of the United States are " arming from 
East to West " for the fight against the 
" Great White Plague." 

Scientific Activity in the Study of Tuber- 
culosis 

Besides all the active, practical work now 
in progress for the prevention and treatment 
of tuberculosis, an immense amount of study is 
being devoted to tuberculosis and the many 
yet unsolved problems in regard to it. In 
laboratories, in sanatoria and hospitals pa- 
tient investigators are at work striving to gain 
more light upon this great subject; and their 
investigations are sure to result in added and 
new methods of fighting the disease. The 
late Prof. Koch, with his band of assistants, 
in his laboratory at Berlin, devoted much of 
224 



THE GREAT CRUSADE 

his life to the study of this disease. One 
might mention scores of names of illus- 
trious men the world over, who, in the se- 
clusion of the laboratory or in the clinics of 
the sanatoria and hospitals, are investigat- 
ing tuberculosis problems. To mention a few, 
we have Behring and Flugge in Germany; 
Prof. Landouzy and Calmette in France; 
Newsholme, Latham and Ransome in Eng- 
land; Phillip in Scotland; Trudeau, Baldwin 
and Theobold Smith in America; Kitasato in 
Japan; Maragliano in Italy. 

It was Flugge of Germany who first demon- 
strated that particles of sputum thrown out in 
coughing contained the tubercle bacilli, and 
Theobald Smith of Boston who discovered the 
difference between the bacillus of cattle and 
the human bacillus. Trudeau has for years 
been studying the conditions of immunity to 
tuberculosis and striving to obtain a serum or 
some form of tuberculin which might produce 
an artificial immunity in man. Much still re- 
mains to be learned about tuberculosis, for 
" Science moves but slowly, slowly creeping on 
from point to point." Still we can only be 
profoundly grateful that we know enough to 
intelligently carry on the Crusade, for we 
know that tuberculosis is preventable and cur- 
able, and we know how this is done. 
225 



TUBERCULOSIS 

Effect of the Tuberculosis Crusade 

This great Tuberculosis Crusade has in- 
directly been of the highest value in stimulat- 
ing the people to increased effort in the im- 
provement of the general conditions of living. 
Undoubtedly many of the measures for pro- 
tecting and uplifting the health of the masses, 
such as the tenement house reforms, factory 
inspection, the provision of more play grounds, 
laws against child labor, and many others, 
are largely due to the tuberculosis campaign, 
for it has been this Crusade which has demon- 
strated to the world the inestimable value of 
cleanliness and fresh air. 

It is evident from the present world-wide 
Crusade that there is a determination to fight 
tuberculosis to the death. From the constant 
increase of all the instrumentalities we have 
been considering, it is apparent that this great 
movement is daily gaining in momentum and 
power. The great awakening is at hand ; and 
from every indication it seems destined to 
grow and grow until the final consummation 
is achieved and the " Captain of the men of 
Death," the Great White Plague, is exter- 
minated. 



226 



XII. TUBERCULOSIS AND THE CHILD 

^^^^^^ HE fight against tuberculosis/'' 
M C^\ sa y s P ro ^ Pannwitz of Berlin, 
K 1 " is in the last analysis an educa- 

^^^^^ tion of the people in social hy- 
giene, and every kind of educa- 
tion should begin in childhood." " Whatever 
we do for the children is for the good of 
future generations," for, as the poet Words- 
worth has so well expressed it, " the child is 
father of the man." It is, therefore, of the 
highest importance to protect the child from 
exposure to tuberculosis, and when it exists, 
to afford it every opportunity for treatment 
and recovery. 

Of late years, especial study has been de- 
voted to tuberculosis in children, for, as evi- 
dence has accumulated, it has been found that 
the disease is much more frequent in child- 
hood, than was formerly supposed, and that 
the frequency of its occurrence increases with 
the age, the greatest frequency being between 
five and fifteen years of age; and during the 

22J 



TUBERCULOSIS 

first years of life it is markedly more prev- 
alent among girls than boys. 

A large number of autopsies made upon 
children dying in hospitals shows a very con- 
siderable amount of tuberculosis, not always 
tuberculosis of the lungs, but, what is common 
in children, tuberculosis of the glands or other 
parts of the body. In brief, it may be said 
that autopsy statistics have shown that tuber- 
culous infection is found in about 40 per cent, 
of all children dying under fifteen years of 
age. 

With the more accurate and newer methods 
of examination, it has also been found that 
tuberculosis is far more frequent in living 
children, as we have said, than was previously 
suspected, or than the death rate would in- 
dicate. Various observers have found in the 
examination of school children that from 29 
to 40 per cent., or more, gave evidence of 
tuberculosis. Thus, in Paris, 40 per cent, of 
school children examined showed signs of the 
disease ; and in the examination of 2,295 cn ^~ 
dren in New York by Dr. Williams, 29 per 
cent, showed tuberculosis of the lungs, while 
Philip of Edinburgh found that among groups 
of children examined in the various public 
schools of that city 30 per cent, gave evidence 
of tuberculosis. Dr. William C. White of 
228 



TUBERCULOSIS AXD THE CHILD 

Pittsburg states that 90 per cent, of all school 
children in our large cities have tubercle bacilli 
in their system before reaching the age of 19 
years. 

Latent tuberculosis, that which is not active 
and produces no symptoms, has been demon- 
strated by Hamburger, a German authority, 
to be present in 71 per cent, of children from 
7 to 10 years, and from 11 to 14 years in 94 
per cent. 

Many good authorities, particularly the 
French and some Germans, believe that most 
cases of tuberculosis become infected in early 
life — in childhood, as the figures first cited 
appear to show — and that during this pe- 
riod the disease remains inactive or latent, that 
is, showing no symptoms. When the child, 
however, undergoes the stress and strain of 
study and confinement in school, or in adult 
life enters into the struggle of earning a liveli- 
hood, with all the coincident depressing influ- 
ences upon the health, the tuberculous infec- 
tion, before latent, becomes active, and 
tuberculosis in some form develops. " The 
harvest of tuberculous disease in mature life," 
says Dr. Kelynack, " is oftentimes dependent 
on a tuberculous seed-sowing in early days." 
" Tuberculosis in early life," he continues, " is 
responsible for many far-reaching disabilities, 
229 



TUBERCULOSIS 

and not a few of life's long-postponed dis- 
asters." 

How Children Contract Tuberculosis 

If so large a proportion of children as the 
above evidence indicates have tuberculosis in 
some form, the natural inquiry is, How did 
they contract it? In the first place, children 
are much more susceptible to infection of any 
kind than adults. We speak of the common, 
acute, infectious diseases, such as measles, 
whooping cough, scarlet fever, etc., as chil- 
dren's diseases, for children contract them 
more frequently and readily than adults. The 
same thing is true with regard to tuberculosis. 
Children are much more susceptible to it than 
adults. Moreover, children cannot resist un- 
hygienic conditions of living, impure air and 
confinement in-doors as well as their elders. 
Added to this, a case of tuberculosis in the 
home, and we have the conjunction of the 
favorable soil and the seed. It is probable, 
then, that very many cases of tuberculosis in 
children arise in a consumptive home, and the 
fact that so many cases of the disease are dis- 
covered in children from such homes is evi- 
dence of the truth of this. Some cases are 
undoubtedly contracted from other school 
children and occasionally from a tuberculous 
teacher. 

23.0 



TUBERCULOSIS AND THE CHILD 

With regard to the channels through which 
the infection takes place, whether by inhala- 
tion — breathing in the germs — or through the 
intestinal tract by means of infected or con- 
taminated food, is still a question upon which 
there is a wide difference of opinion. This 
practically does not make very much differ- 
ence, however, for the method of prevention 
is the same, as we shall presently see. 

Milk Infection 

There is another view of the cause of so 
much tuberculosis among children, and Behr- 
ing, whom we have mentioned before, the great 
German investigator of contagious diseases 
and who discovered the antitoxin of diph- 
theria, is the most ardent supporter of this 
view. It is that milk infection is the cause, 
and that tuberculosis of adults, as he says, 
" is only the concluding chord of the infant's 
cradle song.'' Behring based this view upon 
his experiments with animals, in which he 
found that young animals were almost always 
infected by the food. Milk containing the 
bovine bacilli may infect children, but that it 
frequently does, we have not sufficient proof, 
and much evidence against this theory. For 
example, in Japan, where there are no cattle, 
milk is never used as infants' food, but tuber- 
231 



TUBERCULOSIS 

culosis is just as frequent as in countries 
where milk is used; and in Constantinople, 
where the mothers invariably nurse their chil- 
dren, tuberculosis is very prevalent. N'ansen, 
and other writers upon the Esquimaux in 
Greenland, testify to the great prevalence of 
tuberculosis among them, and here again the 
mothers invariably nurse their children for a 
long period. We have also the statement of 
the great authority, Koch, that the cattle 
bacillus is different from the human bacillus, 
and that the former is rarely found in human 
beings suffering from tuberculosis. He there- 
fore does not believe that milk is a frequent 
cause of tuberculosis in children. " Tubercu- 
losis of the bones, joints, glands, and intes- 
tinal tuberculosis, however, so frequent in 
children, is attributed by many authorities to 
the bovine bacillus carried in milk." We 
should therefore use every means to safeguard 
the milk in this present uncertain state of our 
knowledge upon this subject by assuring our- 
selves that it comes from healthy cows, or by 
sterilizing it. 

House Infection 

We must, then, regard the chief cause of 
pulmonary tuberculosis, at least in children, as 
house infection, and a child in a home where 
232 



TUBERCULOSIS AND THE CHILD 

there is a case of tuberculosis, particularly 
when it begins to creep and handle things and 
puts them in its mouth, as babies constantly 
do, or breathes infected dust, has abundant op- 
portunity to become infected. The kind of 
tuberculosis which we have spoken of before 
as " closed tuberculosis," by which we mean 
that the tubercle bacilli are not thrown off 
from the body, and, consequently, no infection 
of others can take place, is the most common 
kind in children. In this class can also be in- 
cluded tuberculosis of the bones, glands, hip 
disease, scrofula, and intestinal tuberculosis, 
all of which are frequent in children. 

From this fact, that the " closed tuber- 
culosis " is the most common form in children, 
we see the great advantage of treating and 
curing it while it is in this stage and non-in- 
fectious, for thus we kill two birds with one 
stone : we save the child and avoid the danger 
of communicating the disease to others if the 
case was allowed to go on and later become 
" open," that is, with tubercle bacilli in the 
sputum. 

Tuberculosis Not Decreasing in Children 

While tuberculosis has been decreasing 
more or less rapidly among adults, it has not 
done so with children. Thus, in Germany, 

233 



TUBERCULOSIS 

while the mortality rate has been progressively 
decreasing during the years of active a, 
life, the same result has not occurred, or only 
to a very small extent, with children. On the 
contrary, at the ages of from five to ten years 
and from ten to fifteen years, tuberculosis has 
increased. Evidently the modern anti-tuber- 
culosis measures have been devoted more 
especially to adult life than to children; but 
now the tide seems to be turning and children 
are receiving more attention. France, how- 
ever, as we have seen, has always recognized 
the primary importance of attention to tuber- 
culous children and those predisposed to the 
disease, and hence the main efforts in the 
tuberculosis crusade in France have been 
directed to the care and cure of such children. 
In order effectively to carry out the tuber- 
culosis work with children, we must begin 
with the mothers, and children in the home, 
and then with the children in the schools. 
Xursing mothers must be protected and af- 
forded time and opportunity for properly 
caring for their infants and themselves. In 
France there are Mothers' Help Societies, 
which, in various ways, aid in securing care 
and rest for young mothers : and milk dispen- 
saries, called " creches/' which consist of a 

234 



TUBERCULOSIS AND THE CHILD 

hall or ward in a working district where 
working mothers can go and nurse their chil- 
dren without interfering with their work. In 
Italy and Portugal the law requires the estab- 
lishment of such creches in every factory 
where women are employed. For women who 
are unable to nurse their children, sterilized 
or pasteurized milk is furnished in the French 
creches. 

In this country there has recently been 
established near New York, through the be- 
neficent gift of Mr. George H. F. Schrader, a 
home and school for mothers called " Caro- 
line Rest," where poor women, worn-out with 
factory work and household duties, can go 
and rest after the birth of their children. The 
home accommodates thirty mothers and twice 
as many babies and young children. There is 
also connected with this home a corps of 
" Caroline Rest " nurses who visit the mothers 
in their homes before the birth of their chil- 
dren and instruct them in personal hygiene. 
While the mothers are at the home, they 
receive instruction in infant and personal 
hygiene, cooking, etc. 

Children in Infected Homes 

In dealing with the problem of children 
2 35 



TUBERCULOSIS 

of tuberculous parents in the home where the 
surroundings are favorable for the transmis- 
sion of the disease, we must either do what 
we can to protect the child while it remains at 
home or remove it from its dangerous sur- 
roundings. That the danger of contracting 
the disease by the child is great in such 
homes has been shown by Dr. Sachs of Chi- 
cago, who found, in the examination of such 
children, that 28 per cent, between five and 
ten years of age, and 25 per cent, between 
ten and fourteen, gave evidence of tubercu- 
losis. 

In France Prof. Grancher established the 
"League for the Preservation of Children 
from Tuberculosis," the main object of which 
is to remove children of tuberculous parents 
from their homes, where they are daily ex- 
posed to infection, and to send them into the 
country. In his appeal Prof. Grancher said 
that he had for a long time been haunted by 
the leading idea of Pasteur's book on " Dis- 
eases of the Silk Worms," that in order to 
save a race that is threatened by an infectious 
disease, the best plan is to save the cocoon. 
Children taken from tuberculous homes are 
boarded in the country with the farmers or 
236 



TUBERCULOSIS AND THE CHILD 

rural families, and in addition there are rural 
colonies where poor illy-developed children 
from tuberculous homes are afforded a long 
stay in the country or by the sea-side; and 
holiday colonies for school children during 
their vacation. 

In Germany there are also many vacation 
colonies for delicate children, located either 
among the extensive forests which surround 
many of the large German cities, or in the 
open country, or on the sea-coast. The Berlin 
Society for Vacation Colonies has assisted in 
this way over 70,000 children. In Sweden, as 
we have seen, healthy children from consump- 
tive families have been removed and boarded 
out, and two children's homes have been es- 
tablished, with fifty beds, where the children 
are kept until suitable families are found with 
whom they can be placed. In Denmark, 
Switzerland and, indeed, in most coun- 
tries at the present time, vacation or holiday 
colonies exist for weak or sickly children. If 
it were possible to do so, the only sure method 
of safeguarding the children of tuberculous 
parents would be their removal from such 
homes, and placing them in the country under 
wholesome hygienic conditions. 
237 



TUBERCULOSIS 

A Tuberculous Mother Should Not Nurse Her 
Infant 

In the case of the infant of a mother with 
active tuberculosis, under no conditions should 
the latter nurse her child or have it with her, 
for the obvious chances of infection are great, 
not, however, through the mother's milk, but 
through the intimate association of the child 
with its mother. If removed from its tuber- 
culous mother at once, there is strong hope 
that the child will grow up well and healthy, 
if reared under good hygienic conditions, in 
pure air ; for we may repeat again that tuber- 
culosis is not inherited, and whatever tendency 
may be inherited can be, to a great extent if 
not entirely, overcome by a proper environ- 
ment. 

Feeding School Children 

Another means of prophylaxis is the pro- 
vision for poor underfed school children of 
nutritious food by the school or public au- 
thorities. This is done in many countries, but 
especially in Germany and France. In many 
of the German cities soup seems to be the 
usual food furnished. Thus, for example, in 
Strassburg, 2,800 pint bowls of soup are daily 
238 



TUBERCULOSIS AND THE CHILD 

distributed to the local schools. In other 
places milk is furnished. In Dresden, since 
1896, there has existed a special association 
for feeding poor school children with sub- 
stantial food. Supplying free meals to chil- 
dren is not regarded in Germany as coming 
under the head of public charity. This is now- 
done in many schools in this country. 

How to Treat Children with Tuberculosis 

If a child is discovered to have tuberculosis, 
its disposition will depend upon the state of 
the disease, whether it is " closed " or " open." 
If the latter, sanatorium treatment should be 
provided, and this is done in many countries, 
notably in France and Germany. In the 
former country there are about 4,000 beds 
available in the country or sea-side. In the 
sea-side sanatoria, children suffering from 
bone, joint and gland disease are treated. In 
Germany there are eighteen sanatoria with 
900 beds for tuberculous children, and 
seventy-three institutions for suspicious cases 
and those suffering from scrofula. In 
the United States, sanatoria for tuberculous 
children with " open " tuberculosis are, as yet, 
but few and many more are needed. Mention 

239 



TUBERCULOSIS 

has already been made of the Sea Breeze 
Hospital at Coney Island for children with 
bone, joint and gland tuberculosis. 

If the child has " closed " tuberculosis, or 
is predisposed, as we say, to tuberculosis, it 
can under certain conditions attend school, 
and thus at the same time continue its educa- 
tion and take the treatment. These conditions 
are fulfilled by the open-air school, which is 
what its name indicates. If the child under- 
takes the ordinary school routine, it is likely 
sooner or later to break down under it, and 
thus, from an economic standpoint, the 
money expended by the public for its educa- 
tion is lost. In Illinois it has been shown that 
the state expends annually $1,187,000.00 in 
the education of the children who die of 
tuberculosis before their twentieth year. The 
open-air school is established in some open-air 
space, or park, near the city, and the children 
are either directly out-of-doors, or in the 
colder months of the year and in stormy 
weather have some shelter. They are warmly 
clad with thick clothing appropriate for out- 
door life, are well fed and have periods of 
rest during the day. 



240 



TUBERCULOSIS AND THE CHILD 

A Typical Out-Door School 

For the out-door school in Boston, the un- 
used portion of a large building in Franklin 
Park was utilized. A sunny room for the 
kitchen and dining-room, a rest-room, lava- 
tories, and a school-room for stormy weather 
were provided. Upon the spacious roof with 
its pergola, a tent was placed for the chil- 
dren's desks, which was the school-room in 
ordinary weather, canvas curtains being pro- 
vided for high winds. The stormy weather 
room was rarely, if ever, used. Each child 
had a bag of waterproof canvas lined with 
blanketing, fitted about the legs and up over 
the back. In addition, everyone had a thick 
ulster overcoat, warm cap and mittens, woolen 
stockings and arctic overshoes. The home 
conditions were carefully supervised by a 
nurse, who also took the children to dental, eye, 
ear, nose or throat clinics for examination or 
treatment. A director and cook trained the 
children in home hygiene and economics, and 
the director had general oversight of their wel- 
fare. The children were given three meals 
each day of nutritious food. The school board 
provided the teachers and car fares. The daily 
241 



TUBERCULOSIS 

routine was as follows: On arriving at the 
school in the morning, the children had break- 
fast and then some attended to their exer- 
cises in the class-room, while others, for a 
short time, worked in the kitchen and dining- 
room. During the forenoon, there were 
school exercises with a recess, breathing exer- 
cises, play and preparation for dinner. For 
an hour after dinner, all the children rested in 
their sleeping chairs. The afternoon was 
passed as in the forenoon, and after supper 
they returned to their homes. One of the 
scholars, when asked to give the reason why 
he liked the open-air school, wrote : "I like 
the open-air school because I have grown 
stronger and healthier, also because I have 
gained six pounds." 

The number of children in this school was 
twenty-one, from eighteen families, whose 
average number of inmates was six, living in 
apartments averaging four rooms. There 
were thirty-seven tuberculous persons in these 
families, an average of two to each family. 
Thirty-one children had been at the school a 
month or more, and sixteen were returned to 
ordinary schools as arrested cases. 

Experience has demonstrated, as the results 
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TUBERCULOSIS AND THE CHILD 

in the Boston school show, that many of these 
children fully regain their health, and are en- 
abled to return to the ordinary schools. There 
are now in this country nearly 200 open-air 
schools. 

Of course this open-air school for many 
children only partially solves the problem, for 
they have to spend the night at home, often 
under very unhygienic conditions. For chil- 
dren thus situated, the only solution is resi- 
dential open-air school colonies. 

Another important preventive measure with 
children is the care and protection of their 
teeth, which has before been referred to. 
When it is remembered that a large portion 
of school children have decayed teeth so that 
they cannot properly chew their food, the im- 
portance of this prophylactic measure is evi- 
dent. Again, in this connection, it is well to 
refer to enlarged tonsils and adenoids, so com- 
mon in children, and which interfere with full, 
free respiration. Children found to be habit- 
ually breathing through the mouth should be 
examined for these conditions, and if they are 
found to exist, proper measures should be 
taken to remedy them. 



243 



TUBERCULOSIS 

Hygienic School Buildings 

In the ordinary school buildings there is 
■often much to be desired in the provision of 
sufficient space, proper ventilation, light and 
cleanliness, and sanitary arrangements. Every 
school building should be supplied with the 
bubbling drinking fountains, now generally 
used, in place of the dirty common drinking 
cup, and every schoolhouse should have an 
open-air room where weak and anaemic chil- 
dren could receive the benefits of the open- 
air system. Children should be taught to keep 
clean, and avoid putting dirty things in their 
mouths. Above all, the school-room should be 
frequently and thoroughly cleaned, and kept 
clean and free from dust, and an occasional 
regular disinfection would destroy many a 
lurking germ. The provision of play-grounds 
for children now being so actively promoted 
in the United States, both by legislation, as in 
Massachusetts, and by voluntary associations, 
is another evident means of improving the 
health of the child, and hence a valuable pre- 
ventive measure against tuberculosis. Other 
preventive means are children's gardens, 
school farm leagues, the provision of swim- 
ming schools, or tanks for school children, as 
in Brookline, Mass., gymnastics, breathing ex- 
244 



TUBERCULOSIS AND THE CHILD 

ercises, frequent excursions into the country; 
and all the various instrumentalities for im- 
proving the child's health and giving him 
fresh air. The elements of hygiene are now 
almost universally taught in the schools, and, 
in addition, simple facts regarding tubercu- 
losis. In a little pamphlet arranged for school 
children, called " The True Story of Tubercu- 
losis," the following useful rules are given : 

Rules for Children 

1. Do not spit. 

2. Do not let others spit. 

3. If you have a cough, and must spit, use 
a paper napkin or a piece of newspaper, and 
put it in the stove. 

4. Get plenty of fresh air; keep your win- 
dows open at night, no matter what the 
weather may be. 

5. Do not allow anyone to kiss you on the 
lips. 

6. Do not stay near anyone who has a 
cough. 

7. Take a warm bath once or twice a week, 
and bathe your face, neck, chest and arms 
with cold water every morning. 

245 



TUBERCULOSIS 

8. Always hold a handkerchief over your 
mouth and nose, when you cough or sneeze. 

9. Always breathe through your nose. If 
it is stopped up, and you have to open your 
mouth to breathe, go to a doctor or dispen- 
sary. You cannot be well unless you breathe 
through your nose. 

10. Do not wrap heavy mufflers or furs 
around your neck. 

11. Use your toothbrush after each meal. 

12. Wash your hands with soap and water 
before each meal. 

13. Never eat too much. 

14. Drink all the milk you can get, and 
very little tea or coffee. 

15. Do not lie on the bed with a sick per- 
son. 

16. Avoid children who have any contagious 
disease. 

17. Do not spit on your slate, or put your 
fingers in your mouth, before you turn the 
pages of a book. 

18. Do not put things in your mouth that 
other children have had in theirs, such as 
whistles, spit blowers, chewing gum and pen- 
cils. Do not bite from the same apple that 
some one else has been eating. 

246 



TUBERCULOSIS AND THE CHILD 

19. And last as well as first, DO NOT 
SPIT. 

Teachers and Tuberculosis 

Teachers are said to suffer heavily from 
tuberculosis, and Prof. Brouardel states that 
one-fifth of the teachers of Paris are tubercu- 
lous. Although teachers in other countries 
probably do not suffer from tuberculosis to 
this extent, still there is sufficient reason to 
require the periodic examination of all pub- 
lic school teachers, and particularly on enter- 
ing* upon their work, as is done in Denmark, 
where every teacher, on appointment to a 
public school, is obliged to present a medical 
certificate, not more than three months old, 
stating that he (or she) is not affected by any 
contagious form of tuberculosis of the lungs 
or throat. 

The medical inspection of schools is now 
general, but this does not always include the 
examination of the children as regards tuber- 
culosis. From what we have learned of the 
prevalence of tuberculosis among children, it 
would seem that such an examination, as se- 
rious an undertaking as it would be, should, 
at least once a year, be done. 
247 



TUBERCULOSIS 

The Home and Tuberculosis 

After all, it is in the home where there is 
a case of tuberculosis that the greatest dan- 
ger to the child exists, and it is where our 
strenuous efforts must be made. Dr. Low- 
man of Cleveland states the fact that of 504 
children examined by him, who were from 
homes where there was a case of tuberculosis, 
thirty-eight had positive tuberculosis and six- 
ty-four could easily become so infected under 
unfavorable conditions. From the standpoint 
of the child, the value of the visiting nurse 
in connection with the dispensary, of which 
we have before spoken, becomes more ap- 
parent, for whenever a case of tuberculosis 
is discovered, the nurse visits the home and 
urges all the children to be examined. And, 
again, the measures taken by the Information 
Bureaus in Germany, which have been de- 
scribed, in the protection of other members of 
the family in a tuberculous household, are 
shown in this connection to be of the highest 
importance in safeguarding the child. 

A Complete Programme 

Finally, in order to prevent and control tu- 
248 



TUBERCULOSIS AND THE CHILD 

berculosis in children and during school age, 
we must first: Know what children are in- 
fected and those who live in families where 
there is a case of tuberculosis. This can be 
done, in part, through the visiting nurse of 
the dispensary or through whatever agency is 
employed to investigate the home of the con- 
sumptive, and in a more complete, and the only 
satisfactory way, by a periodic examination of 
the lungs of all school children. Second: All 
children who are found to have " open," con- 
tagious, tuberculosis must be placed in sana- 
toria or hospitals, or receive treatment and 
care in the country similar to sanatorium 
treatment. Third : " Closed," non-contagious 
Cases should be placed in open-air schools, 
and, during the summer, in vacation colonies 
or children's camps; or, where the home con- 
ditions are bad, in residential open-air schools 
or colonies. Fourth: Healthy children in 
families where there is a case of tuberculosis 
should either be removed from the family or 
kept under careful observation, or the con- 
sumptive member of the family should be re- 
moved. Fifth: All weak, sickly school chil- 
dren who could easily become tuberculous 
under unfavorable conditions should be placed 
249 



TUBERCULOSIS 

in separate rooms or schools where they can 
receive special hygienic attention, such as 
frequent intermissions for rest, shorter hours, 
food, and an abundance of fresh air. Sixth: 
The children of consumptive mothers should 
not be nursed by them, and should not re- 
main with them. Seventh: All school teach- 
ers should have their lungs periodically ex- 
amined. Eighth: School buildings should 
be so constructed as to be thoroughly venti- 
lated and at all times have pure, fresh air 
and be kept absolutely clean. In every school 
building there should be one so-called open-air 
room. Ninth: School children should be in- 
structed in the elements of hygiene and clean- 
liness, and the simple facts of tuberculosis and 
its prevention. Tenth: Children suffering 
from bone, joint or gland tuberculosis should 
be sent to sea-side sanatoria. 

The above may appear to be a programme 
of perfection and too extensive for any com- 
munity to undertake, but no labor or expense 
is too great in the protection of the child 
from tuberculosis, from which, as we have 
seen, it suffers so severely. What can appeal 
more strongly to the sympathy and interest 
of any anyone than the protection of the in- 
250 



TUBERCULOSIS AND THE CHILD 

nocent, helpless child? Moreover, it is an 
economic gain to the community to save the 
child for future usefulness and contributions 
to the community, rather than to expend large 
sums upon its care when, later, active tuber- 
culosis has developed. 

" The field in which the decisive battle of 
our future campaign against tuberculosis must 
be fought, is the home," says Dr. Woods 
Hutchinson. " Our chief enemy, infection in 
early childhood." Both from an economic, a 
selfish, and a sentimental point of view, the 
most strenuous efforts should be devoted to 
the prevention and arrest of tuberculosis in 
children, for the child of to-day is the man of 
to-morrow, and has infinite and untold pos- 
sibilities. 



25* 



XIII. THE GOVERNMENT AND TU- 
BERCULOSIS 

XN the evolution of popular govern- 
ment, the first step is to render 
life safe and afford protection to 
property — to maintain law and 
order — for no progress and ad- 
vancement in civilization can ensue unless a 
man is made to feel that he can pursue his 
avocation unmolested and remain secure in 
the possession of that which he has gained by 
his labor. As governments have developed, 
however, they have assumed many other func- 
tions with the object of increasing the wel- 
fare and happiness of the people, which a 
general government, with all its power and 
resources, can best or only accomplish. Thus, 
for example, the general government has pro- 
vided or aided in intercommunication between 
the states and foreign countries by means of 
the post office and appropriations for the 
building of pathways of communication in 
252 



GOVERNMENT AND TUBERCULOSIS 

one way or another. Again, the general gov- 
ernment has aided the people in the cultiva- 
tion of the soil by agricultural laboratories, 
experimental stations, and the free distribu- 
tion of seeds. The government is now re- 
claiming the desert wastes of the West on a 
vast scale by means of irrigation, and then 
returning the watered and fertile fields to the 
people for their cultivation. It is protecting 
the forests and coal fields, investigating cat- 
tle diseases, and in very many other ways 
doing for the people those things which they 
could not do, or only with great difficulty and 
slowly do for themselves, and which promote 
the progress and well-being of the whole 
country. Likewise states follow in the foot- 
steps of the general government and perform 
similar offices for their people. Cities, again, 
provide public libraries, parks, baths and play- 
grounds for their constituencies. 

Thus, it is recognized by modern govern- 
ments that whatever adds to the efficiency, 
welfare and happiness of the people, and which 
they individually cannot do for themselves, 
may be properly assumed by the people col- 
lectively, that is, by the government, national, 
state or city. 

253 



TUBERCULOSIS 

The Government Should Protect the Health of 
the People 

The realization that the government could 
promote the welfare of the people by provi- 
sions for the protection of their health seems 
to have come more slowly, and most of the 
steps which have been taken for this purpose 
by the general government have been of com- 
paratively recent date, as, for example, the 
pure food law so recently enacted, and laws 
prohibiting or restricting child labor. It is 
obvious that if we would efficiently protect 
life and property, to say nothing of adding 
to the welfare and happiness of the people, 
the government must aid in protecting them 
from preventable diseases which unnecessar- 
ily destroy life and entail, through sickness 
and untimely death, great financial loss. This 
is especially true of such a prevalent and wide- 
spread disease as tuberculosis. The people 
cannot individually and unaided successfully 
contend with such a gigantic task as eradicat- 
ing this Great White Plague. Private and 
voluntary effort must be supplemented by 
governmental aid, either from the general 
government or state intervention. The lat- 
ter — the state — as we have seen, is realizing 
254 



GOVERNMENT AND TUBERCULOSIS 

its duty in this respect far better than the 
general government. 

In most of the European governments, as 
has been already shown, the tuberculosis Cru- 
sade is aided both by official sanction and 
public appropriations for sanatoria, hospitals, 
and the educational propaganda. In the 
United States we have the great army and 
navy departments with huge annual appro- 
priations of millions of dollars for the pro- 
tection of the life and property of the people 
at home and abroad. We have the Depart- 
ment of Commerce and Labor to promote their 
commercial and industrial welfare; the De- 
partment of Agriculture to aid and show the 
farmer how he can, to the greatest advant- 
age, till his soil and produce the crops best 
adapted to his land. 

But, unfortunately, we have no specific 
Bureau of Public Health to investigate mat- 
ters connected with the health of the people, 
to advocate and carry out measures calculated 
to protect the people's health, or to control 
prevalent diseases. 

What Former President Roosevelt Says 

In his last message to Congress, President 
255 



TUBERCULOSIS 

Roosevelt said: "The recent International 
Congress on Tuberculosis has made us pain- 
fully aware of the inadequacy of American 
public health legislation. This nation can- 
not afford to lag behind in this world-wide 
battle now being waged by all civilized peo- 
ple with the microscopic foes of mankind, nor 
ought we longer to ignore the reproach that 
this government takes more pains to protect 
the lives of hogs and cattle than of human 
beings." Under a National Bureau of Health, 
very many of the yet unsettled questions re- 
garding tuberculosis could properly be investi- 
gated in government laboratories and the re- 
sults practically applied for the benefit of all 
people. The work such a National Bureau of 
Health could do in stamping out tuberculosis 
is almost incalculable, and if .but a small 
fraction of the money now appropriated for 
the army and navy should be devoted to this 
purpose, we should see the disease diminish 
with ever-increasing rapidity. 

State Governments and Tuberculosis 

With but few, if any, exceptions, the vari- 
ous states, as we have seen, have actively en- 
tered into the tuberculosis campaign, both by 
256 



GOVERNMENT AND TUBERCULOSIS 

the enactments of anti-tuberculosis laws and 
the appropriation of money for sanatoria and 
other purposes. Nevada, Utah, Wyoming 
and Mississippi are the only states which have 
made no sanatorium or hospital provision for 
consumptives. Only a few years ago, Penn- 
sylvania appropriated one million dollars 
for dispensaries, sanatoria and the study 
of tuberculosis. The act of the legislature 
making this provision shows such a broad 
and comprehensive grasp of the subject that 
it is well worth while quoting as a model for 
other state governments. The amount ap- 
propriated was divided into two sums: One 
of $600,000, " to provide for the establish- 
ment and maintenance of one or more sep- 
arate sanatoria or colonies in Pennsylvania 
for the free care and treatment of indigent 
persons suffering from tuberculosis and mak- 
ing an appropriation therefor," and the other 
part of $400,000, "to enable the department 
of health to establish and maintain, at such 
places in the state as may be deemed neces- 
sary, dispensaries for the free treatment of 
indigent persons affected with tuberculosis, 
for the dissemination of knowledge relating 
to the prevention and cure of tuberculosis, 
for the study of social and occupational con- 

257 



TUBERCULOSIS 

ditions that predispose to its development, 
and for continuing research experiments for 
the establishment of possible immunity and 
cure of said disease." 

Probably, as Dr. Farrand thinks, the most 
efficient work of the states can be done through 
their boards of health, which, for the state, 
correspond to a National Bureau of Health. 
State boards of health have laboratories for 
the free examination of sputum; they dis- 
seminate tuberculosis literature; they investi- 
gate the tuberculosis conditions in their states, 
and, through them, laws passed by the legis- 
lature are put into execution. It is an en- 
couraging sign to know that the expenditures 
of many state boards of health for health 
purposes have rapidly increased within the 
last ten to fifteen years, whereas, a hundred 
years ago, neither nation nor state spent one 
cent for the protection of health. Thus, in 
Pennsylvania, for example, up to 1904, the 
annual appropriation was only $6,500, while 
for the two years of 1906 and 1907 it was 
$2,100,600, and in 1913, it was $1,629,195 for 
tuberculosis alone. In Massachusetts, in 1895, 
the State Board of Health expended $56,876, 
and in 1913, $1,138,521 for tuberculosis besides 
the expenditure for other preventable diseases. 
258 



GOVERNMENT AND TUBERCULOSIS 

Fighting one preventable disease stimulates 
the health boards and the people to fight other 
preventable diseases, and to generally raise 
the standard of health requirements. The tu- 
berculosis warfare has given an immense im- 
petus towards the improvement of health con- 
ditions in general. 

A Comprehensive Scheme for the State 

Some states have especial tuberculosis com- 
missions for the purpose of studying the prev- 
alence and conditions of the disease within 
their own borders, instructing the people with 
regard to the same, suggesting the best means 
of combating it, and constructing sanatoria. 

Whether it is done by such a commission, 
or by the State Board of Health, a compre- 
hensive scheme adapted to the needs of the 
state should be arranged, with a fixed yearly 
appropriation, so that a systematic and con- 
tinued warfare can be vigorously pushed. 
Such larger undertakings as the erection of 
sanatoria for early cases and consumptive hos- 
pitals for advanced cases, which are beyond 
the means of voluntary and individual effort, 
would naturally fall within the field of public 
provision. 

What is most urgently needed at the pres- 

259 



TUBERCULOSIS 

ent time is greater and more adequate pro- 
vision by the state for the isolation of ad- 
vanced cases. Nothing will so surely and 
steadily reduce this prevalence of tuberculo- 
sis, as we have seen, as such provision for 
hopeless cases, and many states and localities 
are now doing this. 

City Governments 

The cities in their official capacity have, 
and are, doing more or less in the tuberculosis 
warfare. New York City is, perhaps, the 
most conspicuous example of a city possess- 
ing a complete programme for fighting the 
disease, and its efforts have been made 
through the initiative and continued aggres- 
siveness of its very competent Health Depart- 
ment. It was the first city in the country to 
pass a notification law. It has established its 
own sanatorium, and provides extensive ac- 
commodations for advanced cases. It main- 
tains 15 tuberculosis dispensaries, requires 
adequate disinfection of premises which have 
been occupied by a consumptive, and carries 
on very many other administrative schemes 
for the prevention and care of tuberculosis. 
" At the present time," says Dr. Biggs, the 
medical officer of the Department of Health, 
260 



GOVERNMENT AND TUBERCULOSIS 

" there is no other city in the world in which 
the health authorities have so thoroughly or- 
ganized the tuberculosis campaign as in the 
city of New York." That this campaign has 
been effective is shown by the fact that the 
mortality from tuberculosis has been reduced 
more than 53 per cent, since the Depart- 
ment of Health undertook fighting tuberculo- 
sis twenty-five years ago. Other cities have 
followed the admirable example of New 
York to a greater or less extent, in the es- 
tablishment of day camps, dispensaries, mu- 
nicipal sanatoria, and hospitals for advanced 
cases. Boston has all of these, with the ex- 
ception of a sanatorium, which is provided 
by the state. 

Large Appropriations Necessary 

We now possess ample knowledge intelli- 
gently to control and prevent tuberculosis, al- 
though, as has been said, there are unsolved 
problems regarding the disease which are 
still to be worked out in the laboratories and 
clinics. The task of control, however, is 
one of such gigantic magnitude that it re- 
quires large sums of money to accomplish 
it, and this must be furnished through public 
appropriations. " Public Health is Purchase- 
261 



TUBERCULOSIS 

able;'' as the motto of the Department of 
Health of New York City says. As tuber- 
culosis is a people's disease, a " disease of 
the masses," the people must collectively, 
through their government, furnish the means 
to rid themselves of it. To do this will be a 
remunerative investment, and the return will 
be in the preservation of so many lives capable 
of adding greatly to the wealth of the com- 
munity. It is like borrowing money for any 
great public improvement, which will pay for 
itself by the added value it brings to the com- 
munity. All the many existing laws and pro- 
visions made by the states and cities for the 
protection and improvement of the health of 
the people, such as factory inspection laws, 
those regarding tenement-house construction 
and inspection, the limiting of the hours of 
labor, and many others, are obviously indirect 
means for the prevention of tuberculosis by 
increasing the resisting power of the individ- 
ual. 

What Foreign Nations are Doing 

In Germany, there is a National Bureau 
of Health presided over by a cabinet officer, 
which has exhaustively investigated the tu- 
berculosis problem in all its aspects, and, as 
262 



GOVERNMENT AND TUBERCULOSIS 

a result of this study, national laws have 
been enacted, such as the prohibition of in- 
discriminate expectoration, compulsory noti- 
fication, disinfection, and others ; while public 
appropriations have been made for the scien- 
tific study of tuberculosis, the erection of san- 
atoria, etc. The Compulsory Workingmen's 
Insurance Societies, already described, were 
established by imperial decree, in 1881. In 
the German army, careful attention is given 
to the restriction of tuberculosis, and when a 
case is discovered, the soldier is removed to 
one of the government sanatoria, or other- 
wise isolated, and treated. Thus Germany 
shows its wisdom in recognizing the equal 
duty and necessity of protecting the health 
of the workingman, who furnishes the rev- 
enue, as well as that of the soldier, who fur- 
nishes the protection to life and property. The 
German cities have also been active in their 
official capacity in the tuberculosis campaign. 
Some have erected municipal sanatoria, as Ber- 
lin, Strassburg, etc. In others, polyclinics, or 
dispensaries, are maintained. 

In France a permanent commission has been 

appointed by the Minister of the Interior to 

study the causes of tuberculosis and present 

plans for its prevention. In 1902 the Minister 

263 



TUBERCULOSIS 

of Public Instruction caused to be distributed 
in all the schools, colleges, and boarding- 
schools, a circular with instructions concern- 
ing the prevention of tuberculosis. The gov- 
ernment requires all the post offices to be 
inspected to see that proper measures of hy- 
giene are adopted for the protection of the 
staff and the public. The city of Paris 
founded and maintains on the seacoast a 
large hospital of 750 beds for tuberculous 
children. Official aid by the government and 
cities is given in the establishment of san- 
atoria and dispensaries and in other anti- 
tuberculosis work. 

In England there is a British Royal Com- 
mission for Tuberculosis, which was appointed 
in 1901, with the especial purpose of investi- 
gating the difference between the tuberculosis 
of cattle and that of human beings, and it 
has already published several volumes as the 
result of its experiments and investigations. 
Many English cities, by public appropriations, 
provide beds for their consumptives, either 
in already existing sanatoria, or, as in the 
case of the city of Birmingham, already men- 
tioned, establish their own separate insti- 
tutions. The National Insurance Act now 
provides a comprehensive plan with a liberal 
264 



GOVERNMENT AND TUBERCULOSIS 

appropriation for the establishment of sana- 
toria and other provisions for righting tuber- 
culosis. 

Mention has already been made of govern- 
mental activity in the prevention of tuberculo- 
sis in other European countries. We have 
seen what the governments of Sweden, Den- 
mark, Norway and others have done. N In 
Japan, the imperial government has created 
a large hospital for the study and treatment 
of tuberculosis. In the United States, we 
have also seen what many states and cities are 
doing in their official capacity to stamp out 
tuberculosis, and the growing recognition 
throughout the country of the duty of the 
several states in this respect. Over and above 
all this, however, there is needed, as Presi- 
dent Roosevelt so emphatically pointed out, 
" public health legislation," — a bureau of pub- 
lic health,— which will actively engage in the 
battle against tuberculosis. " Science has 
shown," says Dr. Vaughn, " that disease is 
one of the most destructive agents to both 
property and life, and that many diseases are 
preventable. Consequently, the government 
that does not put forth every possible effort 
to protect the property and lives of its citi- 
zens against disease is not doing its duty." 
265 



XIV. THE FACTORY AND THE WORK- 
SHOP IN THEIR RELATION TO TU- 
BERCULOSIS 

QEXT to unsanitary dwellings in 
crowded quarters of the city, the 
factory and workshop are, per- 
haps, the most frequent sources of 
tuberculous infection, and from 
similar causes. In the factory and the work- 
shop the operatives are crowded together, often 
under unsanitary conditions, such as insuffi- 
cient ventilation and light, dust and dirt ; all of 
which are conducive to a deterioration of one's 
health, and hence to the preparation of a suit- 
able soil for the bacillus. Then frequently 
the seed is at hand in a tuberculous workman 
who is negligent in the safe disposal of his 
sputum. Thus the crop of tuberculosis is 
produced, and abundant observation has 
proved the frequency of its occurrence. In 
general, as we know, the mortality of opera- 
tives in shop, mill or factory, is much higher 
than that of those engaged in agriculture and 
266 



FACTORY AND WORKSHOP 

out-door pursuits. Among men in mechanical 
and manufacturing industries, the consump- 
tion death rate is 18.8 per cent, of the mortal- 
ity from all causes, whereas it is only 9.5 
per cent, among men in out-door occupations. 
In England a similar difference is noted, and 
such is undoubtedly the case in industrial in- 
door occupations in other countries. 

Importance of Protecting the Health of Wage- 
Earners 

This high mortality from tuberculosis 
among workers in mills and factories is a 
product or penalty of the present-day civili- 
zation, hence it is a duty of civilization to 
remedy it, and it is of the utmost importance 
that most careful consideration should be 
given to this " occupation disease," as it has 
been called, for the protection of the lives and 
physical well-being of the wage-earners of 
any country means the safeguarding of its 
material prosperity. The influence of the de- 
terioration of the physical condition from 
manufacturing industries is well illustrated 
by the experience of England in the Boer 
war, when so many recruits taken from in- 
dustrial employments were found physically 
26J 



TUBERCULOSIS 

unfit for army service. To maintain a good 
defensive power, a country must preserve the 
health and physical integrity of its common 
people, from whom the mass of its defenders 
are drawn. " There is no doubt," says a re- 
cent writer referring to Germany, " that her 
educational system, military discipline, pater- 
nal supervision of the sanitation of industrial 
establishments, control of insurance of em- 
ployees, all lead to the development of a 
strong, healthy working class, and when to 
these there is added the development of a high 
moral character, the result is a nation well nigh 
impregnable to attack." 

Remedies for Evils of Industrial Infection 

In order to remedy this evil of " industrial 
infection," as it is called, we must work in 
two main directions : first, protect the well 
employees from infection through tubercu- 
lous fellow -workmen ; and, second, so regulate 
and guard the work-places — the shops and 
factories — that all those injurious influences 
which produce a favorable soil, a lowering of 
the resisting power, may be, so far as possible, 
eliminated, — in brief, afford the workman a 
healthy environment to work in. With a large 
number of operatives in a confined space, it is 
almost inevitable that some of them should be 
268 



FACTORY AND WORKSHOP 

tuberculosis, though able to work, and the 
problem is, how to discover and render safe, 
or remove such tuberculous operatives. The 
solution is difficult, and the only perfect way 
would be to examine all persons upon their 
entrance into the factory, or mill, and periodic- 
ally thereafter. In a few instances this has 
been done, as in a large chocolate factory in 
Bristol, England, where every person seeking 
employment has to undergo an examination 
of the heart and lungs. At present, however, 
a general application of this plan would seem 
to be impracticable unless legal enactment by 
the state should require it, and there is much 
to be said in favor of this. Massachusetts, for 
example, now requires that all factories shall 
be well lighted, well ventilated and kept clean ; 
that cuspidors shall be provided; that there 
shall be proper sanitary arrangements; that 
medical and surgical appliances shall be kept 
in all factories; that proper egresses, fire-es- 
capes, and fire extinguishers shall be provided : 
and inspectors are appointed to see that these 
things are done. Why not extend this pater- 
nal care of its working people, and require a 
periodic examination of the lungs of each 
operative, perhaps of equal or greater value 
with these other requirements, when one con- 
269 



TUBERCULOSIS 

siders the frequency of tuberculosis among in- 
door workers? 

What is Now Being Done 

Much, however, is already being done by 
considerate employers and tuberculosis asso- 
ciations for the detection of tuberculosis 
among employees and provision for their treat- 
ment. Placards and notices are displayed in 
workrooms, calling attention to the dangers 
of indiscriminate spitting, and giving some of 
the facts regarding tuberculosis and its symp- 
toms. Cuspidors are provided. In Massa- 
chusetts these are required by law. In the 
government printing office in Washington, 
where 4,800 persons are employed, about 
1,400 cuspidors are provided, which are 
cleaned and sterilized with boiling water and 
steam. In many large establishments, the em- 
ployers offer free examination of the lungs 
to all their employees who think they may 
have tuberculosis, and if a case is discovered, 
it is offered an opportunity to enter a state 
sanatorium for a certain period at the expense 
of the employer. Overseers are asked to seek 
out all who have a cough, or show suspicious 
symptoms of tuberculosis. In a large manu- 
facturing establishment in New England, the 
following notice was posted by the manage- 
ment: 

270 



FACTORY AND WORKSHOP 

" There is at present a strong effort being 
made to exterminate the disease, consumption. 
It is known to be very easily curable if the 
treatment is begun in the early stages, and 
readily prevented by proper ways of living. 
The hopeless or incurable cases are those that 
have been allowed to go neglected. In order 
to aid in this matter we have provided, free 
of expense to our employees, a physician who 
is especially interested in this disease, and 
who can advise about the best treatment ; and 
for the purpose of helping those who may be 
afflicted and protecting others, we shall feel 
free to suggest an examination of any who 
may possibly have symptoms of this disease 
as indicated by coughing, loss of appetite or 
weight. If the lungs are found to be healthy, 
there is then no need to worry; if on the 
other hand, there is any disease, it can be 
treated before it is too late." 

In a considerable number of factories in 
various manufacturing cities in Massachu- 
setts, the employers are co-operating with the 
State Inspectors of Health, who are physi- 
cians, in detecting cases of tuberculosis among 
their employees, or employ physicians them- 
selves for the purpose, and when an early 
case is found, it is sent to the State Sanato- 
rium at the expense of the employer. 
271 



TUBERCULOSIS 

The Plan of Mutual Aid in Connecticut 

In Connecticut a movement has been or- 
ganized in most of the large manufacturing 
cities, whereby both the employers and em- 
ployees unite in caring for tuberculous work- 
men in their respective factories. A certain 
sum of money is subscribed by the working- 
men, and a sum equal to the total amount 
contributed by his men is generally contrib- 
uted by the employer, which combined sum 
is used for the treatment of needy consump- 
tive workmen in sanatoria. The various fac- 
tories thus contributing form a sort of Union 
whereby the weaker ones are aided by the 
stronger. The families of the consumptives 
are also aided by this means. This plan re- 
sembles, in a way, the insurance system of 
Germany. In a number of large manufactur- 
ing establishments provision for the examina- 
tion of employees suspected of suffering from 
tuberculosis, is made at the expense of the em- 
ployer, and this practice is extending. 

If these examples could be generally fol- 
lowed by employers of labor in factories, 
and the operatives themselves would co- 
operate with the employer in the efforts 
to protect them from the danger of tu- 
berculosis infection, much could be done 
in eliminating tuberculosis from the fac- 
272 



FACTORY AND WORKSHOP 

tory. The workman will not, under these 
conditions, seek to conceal his disease for fear 
of losing his position, but rather desire to 
avail himself of the proffered opportunity of 
timely treatment. Many difficulties are, how- 
ever, encountered in the ignorance of the 
operatives and their reluctance to seek an 
examination if they have suspicious symptoms, 
or failure to appreciate the value to them- 
selves or the dangers to which they are expos- 
ing their fellow-workmen. The general dis- 
semination of tuberculosis education through 
labor unions, of which most workingmen 
are now members, and through the placards 
displayed in the mills, and other ways 
will aid in creating an appreciation of, 
and a response to, the efforts made by the 
employers to prevent the spread of tubercu- 
losis in the factory. When it is remembered 
that one " open " case of tuberculosis infects 
at least three others, it is apparent that the 
only safe procedure is to remove every such 
case from the workshop as soon as discovered 
and to make every effort to discover all such 
cases. 

Better Conditions of Factory Life 

The second direction in which we must 
work to eliminate tuberculosis from the fac- 
273 



TUBERCULOSIS 

tory and mill is the provision of a wholesome 
environment for the workman and protection 
from deleterious influences incident to the 
kind of work he is engaged in. Much already 
has been accomplished in this direction by 
the appreciation of their responsibility for the 
health and well-being of their operatives by 
many employers, and by laws enacted by en- 
lightened state governments regarding the 
equipment and inspection of factories and 
mills, the shortening of hours of labor, re- 
striction of woman labor, and the prohibition 
of child labor. 

The ideal to be attained is a clean, well- 
aired and lighted mill, with room sufficient to 
afford each his proper air space, freedom 
from dust or proper apparatus for removing 
dust, and facilities for bathing after the day's 
work. In addition, opportunities for rest at 
the noon hour, in a clean, pleasant room, are 
provided by some employers. What the state 
of Massachusetts requires by law in the direc- 
tion of the fulfillment of the above conditions 
can, perhaps, be taken as an illustration of the 
present attitude of an enlightened public 
opinion with regard to the protection of the 
health of the wage-earner. 
274 



FACTORY AND WORKSHOP 

First: The law requires that all factories 
shall be well lighted, well ventilated and kept 
clean. That " all gases, vapors, dust or other 
impurities injurious to health which are gen- 
erated in the course of the manufacturing 
process or handicraft carried on therein shall, 
so far as practicable, be rendered harmless." 

Second: That adequate washing and sani- 
tary facilities shall be provided. 

Third : " Hoods, suction pipes, fans or blow- 
ers shall be provided for the protection of 
persons using emery wheels or other appa- 
ratus which produces particles of dust inju- 
rious to the health of the employee." 

Fourth : " Suitable receptacles for expecto- 
ration shall be provided in all factories and 
workshops by the proprietors thereof." 

Fifth : " Women employees in manufactur- 
ing, mechanical or mercantile establishments 
shall be provided with suitable seats for their 
use." 

Sixth : The State Inspector of Health shall 
see that these various requirements are carried 
out in factories and workshops, and, further- 
more, " shall inform himself respecting the 
sanitary condition of his district and concern- 
ing all influences dangerous to the public 
275 



TUBERCULOSIS 

health or threatening to affect the same." 
" He shall inform himself concerning the 
health of all minors employed in factories 
within his district, and whenever he may deem 
it advisable or necessary, he shall call the ill 
health or physical unfitness of any minor to 
the attention of his or her parents, or em- 
ployers and of the state board of health." 
This enactment gives authority to the State 
Health Inspector to make a medical examina- 
tion of any person employed in a factory be- 
tween the ages of fourteen and twenty-one 
years, respectively, if, in his judgment, he 
considers it necessary ; and if he discovers tu- 
berculosis, he sees, if possible, that some 
means are provided for proper treatment. 

Mortality from Dusty Trades 

Mr. Hoffman, the accomplished statistician, 
says, in his report upon " The Mortality from 
Consumption in Dusty Trades," in the Bulle- 
tin of the Bureau of Labor of the United 
States, that it is possible by intelligent factory 
inspection and control, and special regard to 
ventilation, to almost entirely eliminate condi- 
tions injurious to health and life in factories 
and workshops, and industry generally, so 
276 



FACTORY AND WORKSHOP 

that the consumption death rate among* wage- 
earners in this country can be reduced to a 
ratio as low as 1.5 per 1,000, which would 
mean an annual saving of, approximately, 
22,238 human lives, and which would repre- 
sent an economic gain of $68,493,000 each 
year ! 

"In New Zealand," Prof. Schrotter tells 
us, " workmen are only admitted to dusty 
occupations after a special examination, which 
is repeated from time to time. Should any 
signs of illness reveal themselves, they are 
immediately dismissed." Would it not be 
wiser to employ means of getting rid of the 
dust? 

Prof. Winslow, of the Massachusetts Insti- 
tute of Technology, gives a striking instance 
of " The Cash Value of Factory Ventilation," 
as he calls it. In a toll room of a telephone 
company there were only windows at front and 
back which could not be, or were not, opened 
in winter, and, consequently, the air became 
vitiated. At a cost of seventy-five dollars, a 
system of ventilation was installed, and fol- 
lowing this change there was a marked im- 
provement in the comfort and general condi- 
tion of the operators. In the winter subse- 
277 



TUBERCULOSIS 

quent to the installation of the ventilating 
system, the average percentage of absences 
among sixty-odd girls was reduced one-half, 
and in the three winter months alone the sav- 
ing amounted to one and eight-tenths the 
entire time of one operator, equivalent to a 
profit of $195 for the company on a capital 
investment of $75.00. 

The Peril of the Sweat Shops 

In the notorious sweat shops and tenement- 
house tailor shops, conditions for the spread 
of tuberculosis are often well-nigh ideal : dust, 
dirt, rags and dried sputum abound; and yet 
we are told that the fashionable tailor sends 
out his cut material to be made up in such 
shops and that the expensive custom-made 
suit is thus manufactured under worse sani- 
tary conditions than a cheap ready-made one. 
Many consumptives work in these shops, and 
expectorate on the floor, thus passing along 
the disease to their unsuspicious neighbor. 
The wages are small, the hours of labor long, 
and the surroundings filthy and most unsani- 
tary. What more favorable breeding places 
for tuberculosis could be conceived ! Seed in 
plenty and the conditions are present for the 
constant manufacture of a fertile soil. A 
278 



, FACTORY AND WORKSHOP 

single example from the observations of the 
state medical inspector of Boston, Dr. Linen- 
thai, will vividly show us how the process 
takes place. A two-room flat on the top of a 
building, situated in a narrow, dirty street; 
three persons living in these rooms, — a young 
man of twenty-five with his mother and 
grandmother. The two women finished pants 
at home, their only means of subsistence ; the 
young man a consumptive and unable to work. 
A small, low-studded room, used as a kitchen 
and workroom, served at night as a bed-room 
for the consumptive; the windows closed, a 
kerosene stove burning, the young consump- 
tive remaining at home all day in this suffo- 
cating air. 

" The inadequate rate of wages," says Dr. 
Linenthal, " the excessive hours of labor, the 
unsanitary state of the shops, make of our 
clothing industry a sweating industry, with all 
the predisposing factors of tuberculosis in 
full operation." The root of the evil, he de- 
clares, is the contract system, — the manufac- 
turer handing over the cut material to the 
contractor, who, in consequence of the close 
competition, makes the goods for a small 
compensation. 

The remedy is public knowledge of the ex- 
279 



TUBERCULOSIS 

isting conditions and a demand for clean 
clothing. The sweat shop, as such, ought no 
longer to exist, for it is a hot-bed for breeding 
tuberculosis. So long, however, as it does, it 
must be rigidly inspected and kept under con- 
stant supervision, and when a consumptive is 
discovered in such places, he should be re- 
moved. The dirty, ignorant, newly arrived 
immigrant, the sweat shop, and the crowded 
tenement, form a combination admirably 
fitted to spread tuberculosis. This combina- 
tion can be broken, however, by arousing 
public opinion, by an efficient active board of 
health and strict and adequate tenement- 
house inspection. 

The Remedy for Dust in Factories 

Reference has already been made to the 
heavy mortality from consumption among per- 
sons occupied in dusty trades, and there are 
but few in which dust is not given off. Many 
investigators have studied the conditions, and 
the general conclusion is that the one universal 
and effective remedy is ventilation : to remove 
the dust at its point of origin, and insure an 
abundant supply of fresh air. That this is 
both practicable and possible at moderate ex- 
280 



FACTORY AND WORKSHOP 

pense, has been shown by an English com- 
mittee appointed to inquire into the ventilation 
of factories and workshops. It seems almost 
incredible that the needless and enormous loss 
of human life from consumption due to dust 
in industrial pursuits and the financial loss 
incurred therefrom, as shown above, should 
be allowed to go on. " Nothing within rea- 
son," says Mr. Hoffman, " should be left 
undone as a national, state, and individual, or 
social, duty to prevent it," and yet, he con- 
cludes, "thus far the problem of scientific 
ventilation and effective dust removal has been 
almost entirely neglected in American estab- 
lishments." 

In this age of industrialism and the eager 
strife for immediate and large pecuniary re- 
sults, human life, of inestimable value, is 
often lightly held and needlessly sacrificed 
on the altar of gain. The most valuable asset 
of any country is men and women of healthy, 
robust physique, and when, in its develop- 
ment, these are sacrificed, the decline and fall 
of that country in no distant future can be 
predicted, as the history of the past has 
shown. 



281 



TUBERCULOSIS 

Department Stores and Shops 

In department stores and shops, there are 
all too frequently rich opportunities for the 
preparation of the favorable soil for the tuber- 
culous infection. A bookkeeper or clerk is 
often tucked away in a gallery, or a corner, 
breathing the hot, vile air from the floor be- 
low, contaminated with dust and nobody 
knows how many infectious germs. Great 
department stores are often most inade- 
quately ventilated and lighted and over- 
crowded. How many young lives are thus 
lost from consumption, the favorable soil for 
which was prepared in this way. Some de- 
partment stores are already realizing their 
obligations to their employees, and provide a 
physician to look after their health in a gen- 
eral way. What should be done, however, 
and the writer ventures to predict that the 
time is coming when it will be done, is to 
examine the lungs of every clerk and em- 
ployee in such establishments upon their 
entrance into the employ of the firm, and 
periodically thereafter. 

Waiters, Nurse Girls and Servants 

The same precaution ought also to be taken 
with regard to waiters: in hotels, who, in the 
writer's experience, have not infrequently 
282 



FACTORY AND WORKSHOP 

been found to be tuberculous, for in the han- 
dling of the food and the intimate associations 
with so many others, the opportunities for 
communicating the disease are great. Again, 
with nursery maids, cooks, and servants in 
private houses, this also should be done. How 
much better to find out that tuberculosis exists 
in such persons before their employment in 
the household than later, when the children 
and family have been exposed to the disease; 
and this is no imaginary fear, — it has hap- 
pened not infrequently. No one desires to 
employ in the family a person who has not 
been vaccinated. Every school child is obliged 
to present a certificate of vaccination upon 
entrance to the school. Is it not at least 
equally important to require evidence of ab- 
sence of tuberculosis in servant and pupil, 
when we consider the enormous prevalence 
of the latter, and the infrequency of small- 
pox? 

Tuberculosis in Prisons 

In former years tuberculosis was very 
prevalent in prisons, so much so that it was 
regarded as a disease peculiar to these insti- 
tutions and called "prison tuberculosis." 
Thus as late as 1893, a report from the Illinois 
State Prison says that fully one-third of the 
283 



TUBERCULOSIS 

1,400 convicts within its walls have consump- 
tion in a light or bad form ; and that nearly all 
deaths in the penitentiary are caused by con- 
sumption. All " long timers " as a rule, it 
continues, " either die within the walls from 
the disease or are pardoned out on account 
of it." 

The cause is very evident, for the prisons 
were crowded, and little if any attention was 
paid to the sanitary conditions and ventilation, 
and the tuberculous inmates mingled freely 
with the others and expectorated at random. 
In part, this condition was due to the igno- 
rance of the communicability of tuberculosis, 
and in part to the old idea that the prisoner 
was there to be punished, not to be reformed, 
and the protection of his health and the pro- 
vision of wholesome conditions of living re- 
ceived but secondary consideration. 

At the present time many prisons and jails 
are still conducted upon the old ideas and are 
woefully defective in proper hygienic con- 
struction and equipment. It is estimated that 
about 15 per cent, of the prison population 
of the country at the present time is suf- 
fering from tuberculosis. The tuberculosis 
Crusade, however, has invaded the penal in- 
stitutions, and both direct and indirect means 
are being employed in many prisons to protect 
284 



FACTORY AND WORKSHOP 

the well inmates from exposures to infection 
and to treat the tuberculous ones by the mod- 
ern methods of out-door life and good 
hygiene. Prison workshops are better venti- 
lated and cleaner, cells are larger and are 
supplied with suitable means of ventilation 
and more light, and are kept clean. The 
physical care of the prisoner is given more 
careful attention in the matter of bathing, 
food and exercise. The new humane idea is 
now gaining ground that the prisoner is a 
human being with a soul, and not a brute, and 
as such should receive such physical and 
moral training as will incite him to reform and 
not to sink deeper in degradation. As a part 
of the responsibility of the state towards the 
prisoner, is his protection from exposure to 
tuberculosis while in captivity. 

In a number of states tuberculosis prisoners 
are now afforded opportunity for taking the 
open-air treatment and are separated from the 
other inmates in order to avoid the possibility 
of communicating the disease to them. In 
Massachusetts a prison hospital or sanatorium 
has been established at Rutland not far from 
the State Sanatorium, to which all consump- 
tive prisoners from the various prisons and 
jails of the state are transferred. At Clinton 
Prison, New York, in the Adirondack Moun- 
285 



TUBERCULOSIS 

tains, there are special wards for the tuber- 
culous prisoners of that state. In Texas is a 
state farm for the same purpose where the 
consumptive prisoners who are able to work 
are employed in light farm work, gardening, 
etc. Previous to the use of this farm, says 
Dr. Ransome, 50 per cent, of all the deaths in 
the prisons of the state of Texas were due to 
tuberculosis, while during the three years of 
existence of the farm the total number of 
deaths in prisoners from this disease was a 
little less than 25 per cent. Much, however, 
remains to be done, for there are now less than 
25 special institutions and hardly 800 beds for 
the 12,000 tuberculous prisoners in the state, 
federal and local prisons and jails of the 
United States. 

Tuberculosis in Insane Asylums 

Formerly tuberculosis was as prevalent in 
insane asylums as in prisons, and from very 
much the same causes. No effort was made 
to control the insane consumptive, and thus he 
infected others, while overcrowding and lack 
of ventilation readily prepared the soil in those 
who were already in a defective physical con- 
dition, as most insane persons are. Fifty 
years ago in one insane hospital in Massachu- 
286 



FACTORY AND WORKSHOP 

setts, 33 per cent, of the deaths in one year 
were due to tuberculosis, and at the present 
time the percentage of deaths from tuberculo- 
sis among the insane is from 50 to 200 per 
cent, higher than among the general popula- 
tion according to the institution. At the 
present time the consumptive insane are seg- 
regated, and in many states provision is made 
for giving them the open-air treatment. The 
result of this has been a reduction of mortality 
from tuberculosis. Thus, in 1900, the aver- 
age mortality in all the New England insane 
hospitals was 11.9 per cent. The general im- 
provement in the care of the insane, and in 
the construction and ventilation of asylums, 
has also contributed to the lessened mortality 
from tuberculosis. Yet the fact remains that 
out of 225 public hospitals for the insane with 
a population of fully 150,000, only 70 or less 
than one-third of them make any provision for 
their tuberculous inmates. So the great 
Crusade against tuberculosis permeates, in its 
beneficent influences, the prison and the asy- 
lum, the workshop and factory, with its mes- 
sage of hope ; and if it does not always bring 
healing on its wings for the afflicted, it tells 
him how he can avoid infecting others, and 
by its gospel of fresh air and good hygiene, it 
shows how best the disease can be resisted. 
287 



XV. THE FUTURE OUTLOOK 

^^_-^^E have come at last nearly to the 
B ^k end of the story of the Great 
V I I White Plague, a story that has 
X^fc^^ not been all sadness in the telling, 
but rather illuminated with great 
hope for the future. We have seen in our 
narrative that tuberculosis is a universal and 
very prevalent disease, affecting mankind at 
the most valuable period of life; that it is a 
contagious or communicable disease, the cause 
of which we know ; and that it is not inherited. 
We have learned that it requires a favorable 
soil in the body to produce the active disease, 
and we have seen how innumerable are the in- 
fluences which produce this favorable soil. 
We have found that it is very curable if taken 
in the beginning, and that the cure is not 
by medicines, but by open-air treatment, the 
method of which, as conducted in a sanato- 
rium or at home, we have learned. We have 
studied the means of prevention, both by con- 
288 



THE FUTURE OUTLOOK 

trolling the source of infection and by render- 
ing the soil unfavorable. The social condi- 
tions which are favorable for the spread of 
the disease have been considered, with their 
remedy, and among them we have seen that 
overcrowding in in-door life, bad air, and the 
abuse of alcohol are three of the most fre- 
quent predisposing causes. Again, we have 
learned that tuberculosis is frequent in child- 
hood, and the various means employed in dif- 
ferent countries to protect the child from 
contracting the disease, and to cure it when 
affected, have been considered. In the great 
crusade against tuberculosis, we have seen 
what the weapons and methods are which the 
various countries of the world are using in 
the warfare; how the educational propaganda 
has extended until the simple facts regarding 
the disease are becoming almost as univer- 
sally disseminated as the waters which cover 
the seas. 

When we consider in detail the means of 
prevention, they seem almost hopelessly many 
and complicated, but the great principles, 
after all, are few and simple : to find out every 
consumptive; to render safe or isolate every 
consumptive; and to improve the living con- 
289 



TUBERCULOSIS 

dition of the masses. It is controlling the 
seed and rendering the soil infertile. As 
gigantic a task as this is, it can be done and 
is already in the process of accomplishment. 

Resolutions of the International Congress 

In this connection it will be well to give 
the resolutions of the International Congress 
at Washington, as indicating the future most 
important lines of effort in the opinion of the 
best authorities throughout the world. They 
are as follows: 

" i. The attention of state and central gov- 
ernments should be called to the importance 
of proper laws for the obligatory notification 
by medical attendants to proper health authori- 
ties of all cases of tuberculosis coming to their 
notice, and for the registration of such cases 
in order to enable the health authorities to 
put into operation adequate measures for the 
prevention of the disease. We urge on the 
public and on all governments the establish- 
ment of hospitals for the treatment of ad- 
vanced cases of tuberculosis. 

" 2. We urge the establishment of sanatoria 
for curable cases of tuberculosis. 

" 3. We urge the establishment of dispen- 
290 



THE FUTURE OUTLOOK 

saries and day camps for ambulant cases of 
tuberculosis which cannot enter hospitals or 
sanatoria. Again the utmost efforts should be 
continued in the struggle against tuberculosis 
to prevent conveyance from man to man of 
tuberculous infection as the most important 
source of the disease. Further preventive 
measures must be continued against bovine 
tuberculosis, and the possibility of the propa- 
gation from this to man should be recognized. 
"Resolved, That this Congress indorse 
such well-considered legislation for the regu- 
lation of factories and workshops, the aboli- 
tion of premature and injurious labor to 
women and children, and the securing of 
sanitary dwellings as will increase the resist- 
ing power of the individual to tuberculosis 
and other diseases ; that instruction in personal 
and school hygiene should be given in all 
schools for the professional training of teach- 
ers ; that wherever possible such instruction in 
elementary hygiene should be entrusted to 
properly qualified medical instructors; that 
colleges and universities should be urged to 
establish courses in hygiene and sanitation, 
and also to include these subjects among their 
entrance requirements to stimulate useful ele- 
291 



TUBERCULOSIS 

mentary instruction in the lower schools. That 
this Congress indorses and recommends the 
establishment of playgrounds as an important 
means of preventing tuberculosis through 
their influence on health and resistance to 
disease." 

A Look Forward 

In conclusion, we are now in a position to 
look forward, and from what has already been 
gained, with some degree of definiteness, fore- 
cast the future. We ask what will be the final 
result of this mighty movement? Can we 
ultimately, within an appreciable period of 
time, eliminate tuberculosis so that it will be- 
come as rare as leprosy, for example, now is? 
Shall we at last free mankind from this its 
inveterate foe? Theoretically, we know we 
can, for we have learned that tuberculosis is 
a preventable and avoidable disease; but can 
this practically be accomplished? 

Those who have been the leaders in the 
great campaign believe that it can, as hercu- 
lean as the task seems to be; and what has 
already been gained in the diminution of the 
disease is strong evidence in support of this 
opinion. " I believe," says Dr. Biggs, the ac- 
292 



THE FUTURE OUTLOOK 

complished medical officer of the New York 
Health Department, " that tuberculosis can be 
practically stamped out," and in support of 
this opinion he says that the reduction in the 
mortality from it in New York City since 1886 
has been about 40 per cent. " I certainly be- 
lieve," said Prof. Vaughan, of the University 
of Michigan, in an address at the Tubercu- 
losis Congress at Washington, " that the time 
will come when tuberculosis will no longer 
curse our race." " We see then," says Prof. 
Irving Fisher, " that the modern Crusade 
against consumption means more than appears 
on the surface. It means, to be sure, the sav- 
ing of the lives of many afflicted with the 
' Great White Plague,' but it means, further, 
a continual lessening in the numbers thus af- 
flicted ... it means that tuberculosis will 
soon be dethroned from its position as chief 
of the diseases, and ultimately eradicated 
altogether." " If every individual in his re- 
spective sphere, and the local state and Fed- 
eral governments would do his full duty," 
says Dr. Knopf, " in the combat of this fear- 
ful scourge of mankind, so justly called the 
' Great White Plague,' I am convinced that 
before many decades tuberculosis would be 
293 



TUBERCULOSIS 

eradicated from our midst." " The Germans 
now look forward," quotes Prof. Lowman 
from a German authority, "with increasing 
confidence, to a new future, to a new golden 
age, when there will be a Germany without 
tuberculosis." " We may reasonably prophesy," 
declared Prof. Brouardel of Paris, at the 
British Congress on Tuberculosis, " that, 
united in one brave attempt, the whole civil- 
ized world will succeed in exterminating the 
cruelest scourge that has ever fallen on us, 
our children and our friends, and which 
threatens the future of our countries." 

At the same Congress Prof. Koch, in his 
memorable address, spoke as follows : " There 
are many, indeed, who doubt the possibility 
of successfully controlling this disease, which 
has existed for thousands of years, and has 
spread all over the world. This is by no 
means my opinion. This is a conflict into 
which we may enter with a surely founded 
prospect of success. . . . This is a visible 
and palpable enemy which we can pursue and 
annihilate, just as we can pursue and annihi- 
late other parasitic enemies of mankind." 

" Science has demonstrated," said former 
President Roosevelt in his letter accepting the 
294 



THE FUTURE OUTLOOK 

presidency of the International Congress on 
Tuberculosis, "that this disease can be 
stamped out, but the rapidity and complete- 
ness with which this can be accomplished de- 
pend upon the promptness with which the new 
doctrines about tuberculosis can be inculcated 
into the minds of the people and engrafted 
upon our customs, habits and laws." 

Twelve years ago the writer of this book 
made the following statement, which, with 
our present knowledge and experience, he 
feels could be made even more emphatic : " I 
firmly believe that it is possible, by a union of 
all the resources at hand — state and law, in- 
dividual and organized exertions, enlighten- 
ment of the public as to the dangers of the 
dried sputum and their avoidance, and the 
utilization of all the means at our command to 
increase the general average of health — so to 
reduce the mortality from consumption that 
it may become one of the rarer diseases in- 
stead of the most common as now." 

Some Statistics of the Diminution of Tuber- 
culosis 

The statistics already at hand of the gen- 
eral diminution of deaths from tuberculosis 

295 



TUBERCULOSIS 

bring the same message of hope for the future 
extermination of the disease. According to 
carefully collected statistical evidence, Mr. 
Hoffman, the statistician of the Prudential In- 
surance Company, shows that in the decade 
from 1 901 to 1 9 10 the death rate from tuber- 
culosis of the lungs in the United States (the 
registration area) decreased 18.7 per cent., 
while the general death rate, including all 
causes of death, declined only one-half as fast. 
This decline in the tuberculosis death rate 
means the saving of 27,000 lives. In the 
Northern and Western cities of the United 
States the death rate from tuberculosis of the 
lungs has declined since 1881 from 325 to 160 
per 100,000 inhabitants, or 50.8 per cent. In 
the Southern cities there has been a decline of 
50.2 per cent, for the whites, and 36.7 per cent. 
for the colored population since 1881. 

In the three industrial Eastern states, 
Massachusetts, Rhode Island and Connecticut, 
with a population of over 5,153,000, from 1881 
to 191 1, the decline has been from 293 in 1881 
to 128 in 191 1 per 100,000 inhabitants, or 56.3 
per cent. In the cities of New York (Man- 
hattan and Bronx), Philadelphia and Boston 
combined, the decline from 1881 to 1912 has 
been from 381. 1 to 180. 1 per 100,000 of pop- 
296 



THE FUTURE OUTLOOK 

ulation, or 52.7 per cent. ; while in the cities 
of New York (Manhattan and Bronx), Phila- 
delphia and Boston singly, the decrease from 
1881 to 1912 has been, respectively: — 53.7 per 
cent., New York ; 48.7 per cent., Philadelphia ; 
and 63.2 per cent., Boston, and in the latter 
city the rate has dropped in twelve years from 
250 per 100,000 to 146, or 42 per cent. In 
Massachusetts the death rate from consump- 
tion has been reduced one-half in the last 
twenty years. 

"All the evidence obtainable," says Mr. 
Hoffman, " confirms the conclusion that the 
reduction of the tuberculosis death rate in the 
United States during the last forty years has 
not been less, but in many cases much more 
than in other civilized countries throughout 
the world." In England and Wales there has 
been a reduction of 43.7 per cent, in the last 
thirty years. In large German cities, from 
1880 to 1909, the death rate from tuberculosis 
has decreased from 346 per 100,000 of popula- 
tion to 179, or 48.2 per cent., while in Amer- 
ican cities during the same period the decrease 
has been 42.3 per cent. This difference in 
favor of German cities is attributed by Mr. 
Hoffman to "the systematic and effective 
treatment and care of tuberculous wage earn- 
297 



TUBERCULOSIS 

ers in special institutions or sanatoria estab- 
lished for the purpose, and many collateral in- 
stitutions and efforts contributory thereto." 

Similar diminution in the death rate from 
tuberculosis is taking place, to a greater or less 
extent, in all countries and cities of the civil- 
ized world, as their various statistics indicate ; 
but enough has been given to prove the success 
of the great warfare against the disease, and to 
give every hope for a continued gradual de- 
crease until the disease becomes practically 
eliminated. " At the present rate of decrease 
in the mortality from consumption," said Dr. 
Abbot, the late secretary of the Massachusetts 
State Board of Health, " it does not seem at 
all impossible that, within the next half cen- 
tury, the sanatoria now occupied by consump- 
tives may possibly be filled by those suffering 
from cancer, since cancer appears to be stead- 
ily increasing while consumption is tending 
towards extinction." We have already seen 
how the leper hospitals in Norway have been 
converted into sanatoria for tuberculosis, now 
that leprosy has been practically extinguished. 

" The real triumph of the campaign against 
tuberculosis," as Mr. Hoffman so justly con- 
cludes, " is the human factor, representing, on 
the one hand, the faith and work of those who, 
298 



THE FUTURE OUTLOOK 

by intelligent co-operation and indefatigable 
industry, have reduced the warfare against 
this disease to a science, and, on the other, the 
immeasurable amount of human happiness 
brought to the countless homes and hearts of 
those who, but for the success which has been 
achieved, would have had only sorrow and 
suffering, and who would have faced the fu- 
ture in helpless despair." 

The Advance in the Future 

It is probable that from this time on, the 
diminution will be slower than it has been in 
the past, for we have already partially cor- 
rected many of the grosser causes of the 
former prevalence of the disease, such as re- 
striction of indiscriminate spitting, the control 
of the advanced consumptive, the protection 
of his family, many of the social conditions 
which predispose to this disease, etc. In the 
future, our work must be more intensive, com- 
prehensive, and systematic. " It is not a 
very difficult problem/' to quote Mr. Hoffman 
again, " to reduce an excessive death rate to 
one of moderate proportions, but it requires 
the highest skill in sanitary administration. 
Using that term in its broadest sense, consid- 
erably to reduce a low death rate still further, 
299 



TUBERCULOSIS 

and most of all in the case of so subtile and 
widely diffused disease as tuberculosis." We 
must work harder, and have a great deal more 
money to work with. " The time is not far 
distant," said Dr. Biggs in 1903, " when those 
states and municipalities which have not 
adopted a comprehensive plan for dealing with 
tuberculosis will be regarded as almost crim- 
inally negligent in their administration of sani- 
tary affairs and inexcusably blind to their 
own best economic interests." In the great ad- 
vances made in the early detection of consump- 
tion and the consequent timely treatment, there 
is and will be increasingly in the future the 
greatest assurance that the individual who has 
the disease will recover; and what a contrast 
this hopeful outlook is to the fonner hopeless 
attitude! Furthermore, the various methods 
of home treatment now being extended and 
generally adopted and this increase of state 
sanatoria bring the opportunities of success- 
ful treatment within the means of the poorest. 

The Open-Air School in the Future 

We have spoken of the open-air schools for 

" closed " cases of tuberculosis in children. 

Their value as a curative and preventive 

measure has been so clearly demonstrated 

300 



THE FUTURE OUTLOOK 

that one can predict with great assurance 
that in the future they will be established 
in all large cities as they already have been 
in nearly 50 cities, and thereby thousands 
of tuberculous children will be cured and 
grow up to make their contributions in va- 
rious channels of useful effort to the com- 
munities in which they live. Nothing is more 
hopeful and encouraging than this work 
with tuberculous children, which, in the fu- 
ture, is destined to become a great and 
important feature of the tuberculosis cam- 
paign. 

Influence of This Movement in Preventing 
Other Diseases 

This great tuberculosis movement has been 
of incalculable value in exciting effort for the 
prevention of other diseases and conditions 
inimical to health, and as time goes on, we 
shall see the results of its influence in this 
direction more definitely. Already there is a 
marked uplift in the living and working con- 
ditions of the masses, but it is just a begin- 
ning. The gospel of fresh air has never been 
so universally proclaimed as it is to-day 
through the influence of the tuberculosis 
movement. A new and mighty impulse has 
been set in motion, looking towards preven- 
301 



TUBERCULOSIS 

tion, due in no small measure to the tuber- 
culosis crusade. As President Eliot has re- 
cently told us, the doctors of the future are 
to be chiefly occupied in the prevention of 
disease, and already the medical schools are 
teaching preventive medicine. May we not 
look forward to a new era in civilization when 
our efforts shall not be exerted so much, as in 
the past, in establishing elaborate and expen- 
sive institutions for the treatment and re- 
straint of those physically or morally diseased, 
but rather for the prevention of those condi- 
tions which make these necessary, the preven- 
tion of disease, poverty and crime. We can 
well repeat the significant words of Mr. Casi- 
mir Perier: "The struggle against tuber- 
culosis is intimately bound up with the solu- 
tion of the most complex economic problems, 
and any plan will be imperfect which has not 
for its foundation the material and moral im- 
provement of the people." 

Another Influence — Peace Between Nations 

One of the great incidental values of the 

world-wide Crusade against tuberculosis is 

the fraternal feeling engendered by the union 

of all nations and peoples for the common pur- 

302 



THE FUTURE OUTLOOK 

pose of preventing and eliminating this com- 
mon enemy of mankind. This is impressively 
emphasized at the International Congresses 
on Tuberculosis such as the one held in Wash- 
ington in 1908 and in Rome in 1912, where 
are gathered physicians, sanitarians, philan- 
thropists and men and women engaged in the 
great conflict from all over the world, repre- 
senting various forms of governments, and 
speaking many tongues, but all with the kind- 
liest feelings, one towards another, because 
they were united by the one single beneficent 
object of stamping out tuberculosis. 

May we not hope that this universal union 
for a common purpose may have a definite 
and real influence in uniting nations closer 
together, and create a deeper realization of 
the value to each of the union of all in efforts 
to stamp out disease and thereby increase the 
welfare and happiness of mankind. May not 
this influence be of value in promoting peace 
between nations, and ultimately lead to a more 
enlightened attitude with regard to the present 
enormous expenditures for war preparations, 
and a mutual agreement to limit, in the future, 
such preparations for the destruction of life 
and property, and to increase their efforts and 

303 



TUBERCULOSIS 

appropriations for the preservation of life and 
the prevention of disease. 

No one would dare predict the rapidity 
with which tuberculosis could be eliminated 
if even a portion of the annual appropriation 
made for military purposes could be em- 
ployed in the warfare against it. We may 
confidently hope that this grand movement 
which has taken possession of the whole civ- 
ilized world will, in the future, accomplish 
more than even the eradication of tubercu- 
losis, — that it will bring together, in friendly 
rivalry to increase the well-being of humanity, 
the nations of the world, promote peace be- 
tween them and put an end to the present 
feverish haste to build up huge armaments, 
and turn the efforts of the governments into 
peaceful and beneficent channels for the pro- 
tection of the health of their people and the 
increase of their happiness. 



3°4 



CHAPTER XVI. THE LUNGS AND 
THEIR USE 

^ m ^ E have learned that nearly nine- 
W H ^ tenths of all cases of tuberculosis 
■ I W are of the lungs — consumption — 
^ f| J and it is, therefore, of the highest 
importance to have some clear 
knowledge of the function and proper use of 
these organs, — we should know something of 
their anatomy, what service they perform, 
how to use them, how to maintain them in 
their integrity, and what injurious influences 
to avoid. If one were to ask a young school 
boy what the lungs were for, he would un- 
doubtedly promptly reply, " To breathe with," 
and if he should then be asked, " Why do we 
breathe ? " he would again as readily reply, 
" If we didn't breathe, we should die." If, 
however, he were asked the third question, 
" Why should we die if we didn't breathe ? " 
he would probably hesitate before answering 
this question, if he answered it at all, unless 
305 



TUBERCULOSIS 

he had arrived at the grade where the ele- 
ments of physiology are taught in the schools. 

Why Do We Breathe? 

Through the medium of the lungs, as we 
know, the oxygen is taken into the body by 
the act of respiration, and carbonic acid (car- 
bon dioxid), a poisonous gas, is given off. 
In other words, respiration does for the body 
what a draught and a chimney do when there 
is a fire in a room: it brings in oxygen to 
unite with the fuel, the absorbed food, and 
produces combustion, and it carries away car- 
bonic acid, the waste product of combustion. 
Through an infinite number of minute blood 
vessels called capillaries, which cover the thin 
walls of the lung cells, or sacs, called 
" alveoli," all the blood of the body passes 
every minute or two, and in its passage the 
oxygen in the air cells, which has been 
brought in by respiration, passes through the 
thin cell walls and enters the blood, while the 
carbonic acid, the waste product of combus- 
tion, passes out of the blood into the cells and 
is carried away by the act. of expiration — 
breathed out. 

After the digested food is absorbed — taken 
306 



THE LUNGS AND THEIR USE 

into the blood — it is carried through the body 
and delivered to the body cells, which con- 
stitute the body tissues and organs, according 
to the needs of each. Within these cells com- 
bustion takes place by the union of the elabo- 
rated food and the oxygen, and, as a result, 
energy is generated. It is like a fire in a 
furnace under a boiler, which produces steam, 
which, in turn, is transmuted into power 
through the medium of the steam engine. Af- 
ter having delivered its supply of fuel and 
oxygen, the blood takes up the waste products 
of combustion, the smoke and ashes, so to 
speak, and carries off some through the lungs 
in the form of carbonic acid, and others 
through the kidneys in other forms. 

Thus heat and energy are constantly fur- 
nished the body, maintaining a fixed tempera- 
ture and enabling it to carry on all the vital 
processes of life. We see, then, how essential 
to life and activity respiration is, and, like- 
wise, how important pure air is to supply the 
constant demand for oxygen. The lungs are 
beautifully adapted for the work they have 
to do. Let us examine their mechanism and 
see how they work. 



3<tf 



TUBERCULOSIS 

The Cavity Which Contains the Lungs 

In the first place, the lungs are safely en- 
sconced in the bony framework of the chest, 
called the thoracic cavity, which is formed by 
the backbone, or thoracic spine, the ribs, which 
are attached to the spine by a hinged, or 
movable joint, and in front by the breast-bone, 
or sternum, to which the ribs are joined by a 
tough, elastic substance called cartilage. The 
top of this thoracic cavity, or chest, is shut in 
by the muscles about the neck, and the bottom, 
or base, is closed by the diaphragm, which is a 
broad, thin, dome-shaped muscle attached all 
around to the bony framework. 

Besides the lungs, the chest cavity contains 
the heart, with its great blood vessels. The 
spaces between the ribs are closed by the in- 
tercostal or between-rib muscles, and they, 
with the diaphragm, are the principal muscles 
in action in ordinary breathing, though in 
forced respiration other muscles about the 
chest are called into play. The intercostal 
muscles pull up and out the ribs so as to 
enlarge the cavity of the chest, expand it, as 
we say, and at the same time the diaphragm is 
drawn downwards by its own contraction so 
308 



THE LUNGS AND THEIR USE 

as to give the expanded lungs more room in 
that direction. 

The Mechanism of Respiration 

When the chest cavity is thus enlarged, the 
air rushes into the lungs and expands them 
so that they fill up the enlarged space. This 
is inspiration. In expiration, the chest walls 
recede and the elasticity of the lung tissue 
contracts them and pushes out the air. Thus 
inspiration is an active process, caused by 
muscular contraction, while expiration is a 
passive one. The act of respiration takes 
place normally from 16 to 20 times a minute. 

In order that the lungs may expand equally 
in all directions, and that their movement in 
respiration may take place smoothly and with- 
out friction, the inside of the chest is lined 
with a thin, delicate membrane, called the 
pleura, which has double walls, the outer one 
being attached to the chest wall and diaphragm 
and the inner one to the lungs. The surface 
of the pleurae is kept moist with a thin, yel- 
lowish fluid, which serves the same purpose 
as oil on the bearings of any piece of ma- 
chinery. Thus, in healthy respiration, the 
movement of the lungs is without sensation. 
309 



TUBERCULOSIS 

When, however, the pleurae become roughened 
by inflammation, as they not infrequently do, 
we at once experience pain in breathing, 
which we call a " pleuritic " pain, or " pleu- 
risy," and in order to avoid the pain we in- 
voluntarily restrict the respiratory movements. 

The Upper Respiratory Tract 

The lungs are connected with the outer air 
by means of, first, the nose, then the pharynx 
behind the mouth, next the larynx lower 
down which leads into the trachea or wind 
pipe, which divides into two great branches, 
one going to each lung, called the bronchi. 
These again are divided into smaller and 
smaller branches until finally they end in the 
tiny air cells, or " alveoli." 

The respiratory tract is lined with a mem- 
brane called " mucous membrane," and is 
moistened with a sticky substance, " mucus." 
There are also on the inner walls of the air 
passages fine hairlike processes, called 
" cilia." The mucus catches the dust particles 
in the respired air, and the " cilia," which 
have a continuous movement upwards, sweep 
out the mucus and dust, thus irritating sub- 
stances in the dust, and whatever bacteria or 
310 



THE LUNGS AND THEIR USE 

germs it contains are prevented from enter- 
ing the lungs. 

Size, Weight and Capacity of the Lungs 

The lungs fit snugly into the pleura-lined 
chest, their rounded top or apex projecting 
into the neck about one and one-half inches 
above the collar bone, or "clavicle," and 
their concave base fitting accurately upon the 
convex top of the diaphragm. The weight of 
the lungs is between 5 and 6 pounds in men, 
and 4 to 5 pounds in women. They have been 
compared to a sponge, because, as we have 
said, they are composed of innumerable cells 
filled with air, and when placed in water they 
will not sink. 

Any impediment to the free movements of 
the chest walls, or action of the muscles of 
respiration, interferes with the free expansion 
of the lungs. Such impediments are some- 
times diseased conditions, or deformities of 
the chest, and sometimes mechanical obstruc- 
tions, such as improper posture, — leaning over 
a desk ; or tight clothing, as corsets. 

When one fills the lungs to their fullest 
extent and then forces out all the air possible, 
the amount thus exhaled is called the " vital 
3ii 



TUBERCULOSIS 

capacity," and is measured by an instrument 
called the " spirometer." This " vital ca- 
pacity" in the average man is about 230 or 
240 cubic inches, and in the average woman 
150 cubic inches. The amount of air one 
generally uses in quiet breathing, called the 
" tidal air," is about 30 cubic inches. Hence 
it is seen how much unused capacity the lungs 
have. In order, then, to give the unused por- 
tion of the lungs proper exercise, we should 
practice deep breathing just as we exercise 
other parts of the body. Full and free respira- 
tion strengthens the lung-tissue and nourishes 
it with well-oxygenated blood; its vitality is 
increased in direct proportion to its work, and 
its resisting force is thereby increased. 

Inadequate Respiration a Danger 

On the contrary, inadequate and partial 
respiration, such as many persons of sedent- 
ary habits and in-door occupations are accus- 
tomed to, throws into disuse more or less of 
the lung-tissue, and reduces its vitality. In 
consequence of this, the nutrition of the lungs 
becomes defective as well as that of the entire 
body, and the lung-tissue becomes an inviting 
soil to disease and the tubercle bacillus. The 
312 






THE LUNGS AND THEIR USE 

deprivation of the pulmonary exercise fur- 
nished by the articulation of words is said to 
be the cause of the frequency of consumption 
among deaf mutes. 

" There is no apparatus," says Lagrange, 
" where we can verify in a more striking man- 
ner the law that ' action makes the organ ' 
than in the respiratory ; no organ is so rapidly 
modified as the lung in accommodating itself 
to the more active working which is de- 
manded of it." The most common seat of at- 
tack from tuberculosis is the tops or apices 
of the lungs, and it is just this portion which 
is so inactive in the ordinary breathing of 
sedentary life. As in quiet respiration the 
diaphragm is the muscle principally in ac- 
tion, there is all the more reason why the 
person of a quiet occupation should regularly 
practice deep breathing in order to exercise 
and maintain in good condition the other 
muscles of respiration. 

"The majority of people," says Prof. 
Schrotter, before quoted, " attach the greatest 
importance to the ingestion of the food, and 
even spend a large proportion of their mental 
activity on the various details in connection 
with their meals, while, as a rule, the process 
3*3 



TUBERCULOSIS 

of respiration, with all that belongs to it, is 
regarded as being less worthy of attention, as 
being of subordinate importance. But if one 
compares the 10,000 litres (610,000 cubic 
inches) of air which a person breathes daily, 
with the small volume of solid and liquid food 
used up by a moderate eater ; if one considers 
that the quality of the air is really much more 
important than that of the diet, and, lastly, if 
one considers that a person can fast for days 
but dies in a few minutes if the respiration is 
stopped, one realizes the error of this view 
and the vital importance of the respiratory 
process." 

We Should Breathe Through the Nose 

In order to maintain the lungs in healthy 
activity, we must have, first, a free entrance 
of air into them through the upper respiratory 
passages ; second, pure air ; third, an adequate 
and unimpaired breathing mechanism, — the 
respiration should be full and free. In the 
first place, we must breathe through the nose, 
which was intended for that purpose. Mouth- 
breathing is pernicious, for it allows the dust 
and whatever uncleanliness is in the air to 
pass directly into the lungs without the prepa- 
ration and sifting which it is subjected to in 
314 



THE LUNGS AND THEIR USE 

the nose. A simple and yet efficacious method 
of curing mouth-breathing is to paste a piece 
of strongly adhesive plaster over the mouth 
on going to bed. The nasal passages should 
be free, and if narrowing or obstructions 
exist, either in front or behind, such as devia- 
tions of the nasal septum (the dividing parti- 
tion) in front, or adenoid growths behind, 
they should be removed. 

The peculiar structure of the nasal passage, 
which forms a sort of winding route for the 
air in its course through it, " over hill and 
dale," enables it thus to sift the air, and free 
it to a great extent from dust and germs; 
warm and moisten it, so that it finally enters 
the lungs clean and of the proper temperature 
and moisture. Even very cold air is, to a 
certain extent, warmed in the nose, so that 
one can breathe the air of the Arctic regions 
with impunity. Warm air likewise does not 
injure the lungs. It is a marvelous provision 
of Nature which enables one to breathe air 
fifty degrees below zero and one hundred and 
fifty degrees above, without harm. 

Importance of Pure, Fresh Air 

Very dry and hot air, such as that so often 
found in a furnace-heated room in winter, 
315 



TUBERCULOSIS 

dries up the nose and throat, and interferes 
with the action of the "cilia/* those con- 
stantly moving sweepers. It is, therefore, im- 
portant that there should be some means in 
living rooms for maintaining a sufficient 
amount of moisture in the air; an average 
relative humidity of about 70 per cent, is most 
wholesome and comfortable. 

The air which we breathe should be pure 
and fresh, as we have learned many times in 
the course of this narrative. It should be 
free from dust, smoke and carbonic acid, as 
in air breathed and rebreathed in a crowded 
room with insufficient ventilation. Absolutely 
pure air can nowhere be obtained in civilized 
communities, — there are always more or less 
impurities in it ; but we can breathe the purest 
air there is about us. Night air, as has been 
before mentioned, is as good as, and some- 
times purer than, day air. The inhalation of 
smoke, a common habit with cigarette smok- 
ers, irritates the delicate lung-tissue, and 
renders it more susceptible to infectious 
germs. 

Respiratory Exercises 
With a free passage through the nose, and 
316 



THE LUNGS AND THEIR USE 

the purest air we can obtain, the next thing 
is to ensure full and free respiration, and this 
we must do by general and respiratory exer- 
cises. 

(a) General Exercises: Many general ex- 
ercises are good for respiration, such as swim- 
ming, running, tennis, skating, rowing, moun- 
tain climbing, free hand class work in a gym- 
nasium, dancing, singing, rope jumping, etc. 
It is said that rope jumping is a common form 
of exercise with boxers for increasing the 
" wind." All exercises which bring the legs 
into violent action are especially good for 
respiration on account of the number and size 
of the muscles employed. 

(b) Special Exercises: Besides these gen- 
eral exercises, there are other direct, or local, 
respiratory ones, especially directed to the de- 
velopment of the respiratory muscles and 
lungs. These especial respiratory exercises 
are simple and yet efficacious, such as, stand- 
ing erect in a well-ventilated room, or, better, 
out-doors, with the hands on the hips and tak- 
ing long, deep inspirations and slow expira- 
tions, beginning at the bottom of the chest and 
filling up, so to speak. This alone, done sev- 
eral times a day, will often materially in- 

317 



TUBERCULOSIS 

crease the lung capacity. " Numerous obser- 
vations," says Lagrange, " prove that it is 
enough voluntarily to take a certain number 
of deep breaths every day to produce in a 
short time an increase in the circumference of 
the chest which may amount to two or three 
centimetres." Then there are the various arm 
movements in connection with deep breathing, 
such as slowly raising the outstretched arms 
to a horizontal position and then overhead 
until the hands meet, slowly and deeply in- 
spiring while raising the arms, then holding 
the breath a moment, and, finally, lowering 
the arms and exhaling. Thus the supplement- 
ary respiratory muscles of the chest are 
brought into action. Again, raising the arms 
to a horizontal position and carrying them 
back and down, describing a movement of 
circumduction; standing erect and straighten- 
ing up, and, finally, rising upon one's toes, 
deeply inspiring during this movement; lying 
on the back horizontally upon the floor, or a 
table, and raising the arms backward and over 
the head while inspiring. If the table is nar- 
row, the arms can describe a circle about the 
head. 

Still another simple breathing exercise men- 
tioned by Schrotter is the following: The 

318 



THE LUNGS AND THEIR USE 

chest being well thrown forward and the arms 
placed akimbo, the shoulders are moved back- 
wards in jerks as far as possible, and then a 
deep inspiration is taken. This can be taken 
while walking out-of-doors. In the Swedish 
system of gymnastics, there are almost an in- 
numerable variety of respiratory exercises, 
most of which, however, are but modifications 
and combinations of a few simple movements, 
and many can be performed without appa- 
ratus. Again, there are the common gym- 
nastic apparatus for increasing the lung 
capacity and developing the respiratory mus- 
cles, such as the so-called " chest developers " 
and " lung expanders." The Zander appara- 
tus can also be the ones for the same purpose. 
After all, the simple deep-breathing exer- 
cises will be the ones most generally applica- 
ble, for anyone can do them anywhere. After 
sitting at the desk for a long time, particularly 
if bent over, it is a good plan to stand up and 
spend a few minutes in practicing some of the 
simple breathing exercises. "What is gen- 
erally described as overwork," to quote Prof. 
Schrotter again, " is really the effect of stay- 
ing too long in a close atmosphere and of an 
insufficient activity of the respiratory organs." 



319 



TUBERCULOSIS 

The Corset 

It is hardly necessary to say that in taking 
breathing exercises one should be so dressed 
as not to impede the free movement of the 
chest. The corset has already been referred 
to. From time immemorial physicians have 
decried them as interfering with the free 
movement of the chest in respiration, and im- 
pairing the integrity of the respiratory mus- 
cles. From time immemorial women have 
worn them, and will probably always continue 
to do so, in spite of the evils from them which 
they too well know. It is fortunate that they 
are removed at night, and thus for a portion 
of the twenty-four hours the lungs are al- 
lowed free play. 

The Habit of Full, Free Respiration 

Once having established a proper respira- 
tion by the use of some of the simple respira- 
tory exercises, and devoting a few minutes to 
them every day, the habit of full, deep breath- 
ing is formed, and one continues it to a 
greater or less degree even when in repose. 
And, further, one is thus fortifying himself 
against the possibility of disease of the lungs 
by thus maintaining the pulmonary tissue in 
320 



THE LUNGS AND THEIR USE 

an active, healthy and well-nourished condi- 
tion, and it is less likely to become a favora- 
ble soil for the tubercle bacillus. 

Let me repeat and emphasize in closing, 
that this matter of chest expansion and proper 
respiration is of vital importance to every one, 
particularly to those of sedentary habits. By 
employing this simple precaution, we not only 
put ourselves in the most favorable condition 
to avoid pulmonary weakness and disease, but 
maintain the whole circulation in a healthy 
condition, which means vigor and well-being 
to the entire system. A nation of deep 
breathers can do much toward stamping out 
and banishing forever the " Great White 
Plague." 



321 



FRESH AIR 1 

The more fresh air we give to our school- 
children the healthier and brighter will they be, 
and the faster will they get ahead. This has 
been proved. 

The same is true of workers in shops, offices, 
and factories. Shall they not be helped to do 
their best work? 

Get more fresh air into your workshops and 
places of business. 

Remember, fresh air is needed in our homes. 
Night air is just as good as day air. 

The air in theaters and restaurants and pub- 
lic halls, crowded as such places are every 
night, ought also to be kept fresh. Patronize 
only those that are well ventilated. 

Fresh air is entirely free. It is always wait- 
ing just outside the window-pane. Don't be 
stingy with it! Let it in! 

Always work, sleep, and play where fresh 
air is plenty, and keep out-of-doors whenever 
possible. 

When in doubt — open a window. 

1 Prepared by the Boston Association for the 
Relief and Control of Tuberculosis. 
322 



HEALTH RULES 1 
Good Air 

Keep away from badly ventilated, badly 
lighted, dusty, dirty, over-heated, crowded or 
damp rooms. Keep a window open. 

Avoid House Dust 

Breathing house dust often causes disease. 

Have no tacked-down carpets and mattings. 

For floor coverings use rugs or strips of car- 
pets, and clean them frequently outdoors. 

Use a broom or mop for floors and keep 
lower half of window closed while sweeping or 
dusting. 

Open upper half of window if possible. 
When sweeping rugs or carpets dampen the 
broom or use wet sawdust or wet pieces of 
paper, and in winter use dry snow. This will 
keep the dust from flying about. 

Pure Water 

Drink pure water from the tap. 
Boston water is safe to drink. 

1 Prepared by the Boston Association for the 
Relief and Control of Tuberculosis. 

323 



TUBERCULOSIS 

Water standing in ice-water tanks may be- 
come contaminated. 

Avoid public drinking cups. 

Keep Clean 

Take a bath or wash the body with a wet 
sponge or cloth every day. If you have no 
bath tub use the public bath. 

Do not use towels hung up for common use. 

Use pure soap freely. 

Wash your hands thoroughly, and clean your 
finger nails before handling food. 

Do not put fingers, money, paper, or pencils 
in your mouth. 

Do not put in your mouth fruit, candy, or 
chewing gum used by another. 

Do not bite your finger-nails. 

Clean your teeth every day, using your own 
tooth brush. 

Food 

Do not eat food that has been exposed to 
flies or dust, or touched by unclean hands. 

Fruit and vegetables should be rinsed or 
washed thoroughly before using. 

Chew your food well. 

Good teeth promote good health. 

324 



HEALTH RULES 

Sleep 

Get enough sleep. Most people need 8 
hours a day. 

Growing children need 10 hours. 

Sleep with windows open and when possible 
outdoors. 

Head Erect 

Sit and stand erect. 

Practise deep breathing. Breathe through 
the nose, keeping the mouth closed. 
Avoid tight clothing. 
Stand on both feet. 

Exercise 

Take plenty of out-door exercise. 
Avoid excess in athletics. Too much exer- 
cise may cause heart trouble. 

Do not eat or drink when overheated. 
Do not exercise soon after eating. 

Tobacco and Liquor 

Do not use tobacco, liquor or beer. Drink- 
ing or smoking is especially injurious to the 
young. 

No athlete in training is allowed to drink or 
smoke. 

Tea drinking is bad for growing children. 

325 



TUBERCULOSIS 

Do Not Neglect Colds 

Do not neglect coughs or colds. If you do 
not get well soon, go to a doctor or dispensary 
for treatment. 

Never cough or sneeze into another person's 
face. 

Use a handkerchief or turn your head away. 

Do not spit on floors or sidewalks. 

Sunshine 

Let plenty of sunshine into your rooms. 

Joy is a great tonic. 

Happiness in work brings success. 



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